Children’s Uninsured Rate Rises by Largest Annual Jump in More Than a Decade by Joan Alker and Alexandra Corcoran Key Findings zz After reaching a historic low of 4.7 percent in 2016, the child uninsured rate began to increase in 2017, and as of 2019 jumped back up to 5.7 percent. This increase of a full percentage point translates to approximately 726,000 more children without health insurance since the beginning of the Trump Administration when the number of uninsured children began to rise. Much of the gain in coverage that children made as a consequence of the Affordable Care Act’s major coverage expansions implemented in 2014 has now been eliminated. zz The number of uninsured children increased every year during the Trump Administration. The largest increase was observed between 2018 and 2019 when, despite a continued strong economy, the number of children without health insurance rose by 320,000. This increase in the number of uninsured children was the largest annual jump seen in more than a decade. Moreover, since this data was collected prior to the pandemic, the number of uninsured children is likely considerably higher in 2020, as families have lost their jobs and employer-sponsored insurance, though it is impossible to know yet by precisely how much. zz One-third of the total increase in the number of uninsured children from 2016 to 2019 live in Texas. The state saw by far the greatest coverage loss over the period with an estimated 243,000 more children living without health coverage. Florida has the next biggest loss, adding about 55,000 children to the uninsured count over the three-year period. As a consequence, 41 percent of children’s coverage losses during the Trump Administration occurred in Texas and Florida. Twenty-nine states experienced an adverse change for children from 2016 to 2019. The only state that bucked national trends and significantly reduced its number of uninsured children during this three-year time period was New York. zz These coverage losses were widespread across income, age, and race/ethnicity, but were largest among White and especially Latino children (who can be of any race). October 2020 CCF.GEORGETOWN.EDU children’s uninsured rate jumps 1 Introduction For many years, the United States was on a positive consequence of the ACA’s major coverage expansions has trajectory in reducing the number and rate of uninsured now been eliminated. Moreover, the most recent year of data children; in 2016, the nation attained a historic low of 3.6 (2018 to 2019) shows the biggest one-year loss in children’s million uninsured children. This progress occurred as a coverage during this time period, with 320,000 more result of expansions of public coverage—primarily Medicaid children becoming uninsured (Figure 3). These coverage and the Children’s Health Insurance Program (CHIP)—and losses occurred in a healthy economy with the lowest was accelerated by the implementation of the Affordable unemployment rate in decades prior to the economic shocks Care Act’s (ACA) major coverage expansions in 2014.1 and job loss associated with the COVID-19 pandemic.5 As employer-sponsored insurance became increasingly unaffordable for dependents,2 public coverage ameliorated the impacts of private coverage losses for children.3 These coverage losses occurred in a healthy However, the number of uninsured children began to economy with the lowest unemployment increase in 2017 as Medicaid enrollment began to decline, rate in decades prior to the economic and as Figure 1 shows, reached 4.4 million in 2019.4 This represents an increase of 726,000 children during this shocks and job loss associated with the three-year period. The rate of uninsured children rose a full COVID-19 pandemic. percentage point from 4.7 percent to 5.7 percent (Figure 2). Much of the gain in coverage that children made as a Figure 1. Number of Uninsured Children in the United States (in millions), 2008-2019 7.6 7.1* 6.7* 6.2* 5.9* 5.9 4.9* 4.4* 4.0* 3.9* 4.1* 3.6* 2008 2009201020112012201320142015 2016201720182019 Source: Georgetown University Center for Children and Families analysis of the U.S. Census Bureau American Community Survey (ACS) Table HIC-5, Health Insurance Coverage Status and Type of Coverage by State - Children Under 19: 2008 to 2019, Health Insurance Historical Tables. *Change is significant at the 90% confidence level relative to the prior year indicated. 2 children’s uninsured rate jumps CCF.GEORGETOWN.EDU October 2020 Figure 2. Rate of Uninsured Children, 2008-2019 9.7% 9.0%* 8.5%* 7.9%* 7.5%* 7.5% 6.3%* 5.7%* 5.1%* 5.0%* 5.2%* 4.7%* 20082009 20102011 2012 2013 20142015 2016 20172018 2019 Source: Georgetown University Center for Children and Families analysis of the U.S. Census Bureau American Community Survey (ACS) Table HIC-5, Health Insurance Coverage Status and Type of Coverage by State - Children Under 19: 2008 to 2019, Health Insurance Historical Tables. *Change is significant at the 90% confidence level relative to the prior year indicated. Figure 3. Annual Growth in the Number of Uninsured Children, 2016-2019 350,000 320,000* 300,000 276,000* 250,000 200,000 130,000* 150,000 100,000 50,000 0 2016-2017 2017-2018 2018-2019 Source: Georgetown University Center for Children and Families analysis of the U.S. Census Bureau American Community Survey (ACS) Table HIC-5, Health Insurance Coverage Status and Type of Coverage by State - Children Under 19: 2008 to 2019, Health Insurance Historical Tables. *Change is significant at the 90% confidence level relative to the prior year indicated. October 2020 CCF.GEORGETOWN.EDU children’s uninsured rate jumps 3 Figure 4 shows how the sources of children’s coverage The loss of public coverage can be attributed to a range have changed, though data is not yet available to look at of factors including large cuts in outreach and enrollment the three-year trend. From 2017 to 2019, a small increase assistance and efforts to undermine the ACA;6 a “chilling in employer-sponsored insurance for children was not effect” created by the Trump Administration’s public charge large enough to offset the loss of Medicaid/CHIP coverage regulation and other actions leading to a hostile climate for that has contributed to the rise in the uninsured rate. The immigrant families that has deterred many mixed-status share of children covered by insurance purchased directly families from enrolling their eligible children (most of whom from an insurance company or subsidized coverage are citizens) in Medicaid and the Children’s Health Insurance through a federal or state Marketplace created by the Program (CHIP);7 and red tape barriers that make it harder ACA, has also declined. for families to enroll or stay enrolled in Medicaid/CHIP.8 Figure 4. Sources of Children’s Coverage, 2017-2019 Employer- Direct- Un- sponsored Medicaid/CHIP Other purchase insured 2017 47.4% 34.4% 7.7% 5.4% 5.0% 2019 48.1%* 33.5%* 7.8% 5.0%* 5.7%* 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Source: Georgetown University Center for Children and Families analysis of the U.S. Census 2017-2019 American Community Survey (ACS), Table B27010. * Change is significant at the 90% confidence level relative to the prior year indicated. 4 children’s uninsured rate jumps CCF.GEORGETOWN.EDU October 2020 Which states are seeing the biggest increases? Over the three-year period, 26 states have seen a significant 343,000 uninsured children in 2019—the second largest jump in their number of uninsured children since national number in the nation. These two states account for 41 progress halted and began reversing in 2017 (see Table percent of the increase in children without health insurance 1). Texas saw an enormous increase of 243,000 children, coverage nationwide. Other states that saw increases of accounting for about one-third of the increase in uninsured more than 20,000 uninsured children during the three-year children nationwide. Approximately 1 million children in period include: Illinois, California, Arizona, North Carolina, Texas were uninsured in 2019. In Florida, about 55,000 more Ohio, Missouri, Utah, Tennessee, and Indiana. See Table 1. children were uninsured bringing its total to an estimated Table 1. 26 States with Significant Increase in Number of Uninsured Children, 2016-2019 (ranked by largest to smallest number change) 2016 Number 2019 Number 2016-2019 Change in State Uninsured Uninsured Number of Uninsured United States 3,649,000 4,375,000 726,000 Texas 752,000 995,000 243,000 Florida 288,000 343,000 55,000 Illinois 82,000 120,000 38,000 California 300,000 334,000 34,000 Arizona 132,000 161,000 29,000 North Carolina 115,000 142,000 27,000 Ohio 104,000 131,000 27,000 Missouri 71,000 95,000 24,000 Utah 59,000 82,000 23,000 Tennessee 58,000 80,000 22,000 Indiana 99,000 119,000 20,000 South Carolina 50,000 69,000 19,000 Colorado 57,000 73,000 16,000 Arkansas 30,000 43,000 13,000 Louisiana 39,000 50,000 11,000 Kentucky 35,000 45,000 10,000 Kansas 34,000 43,000 9,000 Mississippi 37,000 46,000 9,000 Alabama 32,000 40,000 8,000 Nevada 50,000 58,000 8,000 Washington 46,000 54,000 8,000 Massachusetts 15,000 22,000 7,000 Oregon 31,000 38,000 7,000 South Dakota 11,000 18,000 7,000 West Virginia 9,000 13,000 4,000 Montana 12,000 15,000 3,000 Source: Georgetown University Center for Children and Families analysis of the U.S. Census Bureau American Community Survey (ACS) Table HIC-5, Health Insurance Coverage Status and Type of Coverage by State - Children Under 19: 2008 to 2019, Health Insurance Historical Tables. October 2020 CCF.GEORGETOWN.EDU children’s uninsured rate jumps 5 Only one state, New York, saw a significant improvement in year period, with 26 states seeing statistically significant the number of uninsured children. The remaining states saw no change on this measure. In total, 29 states experienced a significant change one way or the other (Appendix Table 3). statistically significant adverse change in rate or number during the three-year period. The rate of uninsured children (as opposed to the number) is an important indicator to examine how states are doing As Table 2 shows, the states with the biggest jumps, of more in comparison with each other and accounting for relative than 1.5 percentage points, are: South Dakota, Texas, Utah, size. As a whole, the country experienced a 1 percentage Arkansas, Missouri, Delaware, Arizona, and South Carolina. point increase in the child uninsured rate during the three- Table 2. 26 States with Significant Increase in Rate of Uninsured Children, 2016-2019 (ranked by largest to smallest rate change) 2016 Percent 2019 Percent 2016-2019 State Uninsured Uninsured Rate Change United States 4.7 5.7 1.0 South Dakota 4.7 7.8 3.1 Texas 9.8 12.7 2.9 Utah 6.0 8.3 2.3 Arkansas 4.0 5.9 1.9 Missouri 4.8 6.5 1.7 Delaware 3.1 4.8 1.7 Arizona 7.6 9.2 1.6 South Carolina 4.3 5.8 1.5 Illinois 2.6 4.0 1.4 Kansas 4.5 5.8 1.3 Mississippi 4.8 6.1 1.3 Montana 4.9 6.2 1.3 Tennessee 3.7 5.0 1.3 Colorado 4.3 5.5 1.2 West Virginia 2.3 3.5 1.2 Indiana 5.9 7.1 1.2 Louisiana 3.3 4.4 1.1 North Carolina 4.7 5.8 1.1 Florida 6.6 7.6 1.0 Kentucky 3.3 4.3 1.0 Ohio 3.8 4.8 1.0 Oklahoma 7.7 8.6 0.9 Alabama 2.7 3.5 0.8 New Jersey 3.7 4.3 0.6 California 3.1 3.6 0.5 Massachusetts 1.0 1.5 0.5 Source: Georgetown University Center for Children and Families analysis of the U.S. Census Bureau American Community Survey (ACS) Table HIC-5, Health Insurance Coverage Status and Type of Coverage by State - Children Under 19: 2008 to 2019, Health Insurance Historical Tables. 6 children’s uninsured rate jumps CCF.GEORGETOWN.EDU October 2020 Uninsured children are disproportionately living in the South A disproportionate share of uninsured children live in the lowest child uninsured rate and did not see any significant South (52.7 percent), and this trend has worsened over the rise in the number of uninsured children during the period three-year period. (See Table 3.) Sixty-one percent of the examined. (See Table 4.) Appendix Table 5 shows the top 20 increase in uninsured children has been in the South. The counties, located in eight states, where uninsured children Midwest and the West also saw increases over this time live—the counties where Houston, Dallas, and Phoenix are period, albeit smaller. As a region, the Northeast has the located all have more than 100,000 such children. Table 3. Share of Uninsured Children by Region, 2019 Number of Geographic Share of the Total Share of Nation’s Uninsured Uninsured Rate Region Child Population Uninsured Children Children Midwest 21.0% 762,000 17.4% 4.7% Northeast 15.8% 398,000 9.1% 3.3% South 39.0% 2,307,000 52.7% 7.6% West 24.2% 910,000 20.8% 4.9% United States 100.0% 4,377,000 100% 5.7% Source: Georgetown University Center for Children and Families analysis of the U.S. Census Bureau American Community Survey (ACS) Table HIC-5, Health Insurance Coverage Status and Type of Coverage by State - Children Under 19: 2008 to 2019, Health Insurance Historical Tables. Data may not sum due to rounding. Table 4. Change in Number of Uninsured Children by Region, 2016-2019 Geographic Number of Uninsured Number of Uninsured Change in Number of Region Children 2016 Children 2019 Uninsured Children Midwest 628,000 762,000 134,000* Northeast 383,000 398,000 15,000 South 1,862,000 2,307,000 445,000* West 778,000 910,000 132,000* United States 3,651,000 4,377,000 726,000* Source: Georgetown University Center for Children and Families analysis of the U.S. Census Bureau American Community Survey (ACS) Table HIC-5, Health Insurance Coverage Status and Type of Coverage by State - Children Under 19: 2008 to 2019, Health Insurance Historical Tables. Data may not sum due to rounding. * Change is significant at the 90% confidence level relative to the prior year indicated. Geographic Regions: 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 – AK, AZ, CA, CO, HI, ID, MT, NV, NM, OR, UT, WA, WY October 2020 CCF.GEORGETOWN.EDU children’s uninsured rate jumps 7 In 2019, 13 states had rates of uninsured children that were significantly higher than the national average, 12 states were at the national average, and 25 states and D.C. were doing better than the national average. See Figure 5. Figure 5. 13 States Had Significantly Higher Rates of Uninsured Children than the National Rate in 2019 3.1 3.7 2.1 5.6 6.2 7.8 1.5 4.1 3.1 1.9 5.0 7.8 2.4 3.8 3.5 10.6 3.4 4.3 2.9 4.6 5.7 3.4 8.0 4.8 4.0 7.1 4.8 8.3 5.5 3.5 3.6 5.8 4.9 2.0 6.5 4.3 5.8 5.0 9.2 8.6 5.9 No statistically significant difference 5.7 5.8 6.1 from the national average (12 states) 3.5 7.4 Uninsured rate significantly lower 12.7 4.4 than national rate (25 states and D.C.) 7.6 Uninsured rate significantly higher 9.4 than national rate (13 states) 2.8 Source: Georgetown University Center for Children and Families analysis of the U.S. Census Bureau American Community Survey (ACS) Table HIC-5, Health Insurance Coverage Status and Type of Coverage by State - Children Under 19: 2008 to 2019, Health Insurance Historical Tables. Which children were more likely to be uninsured? Latino children (who can be of any race) saw the biggest rate ranged from 2.3 percent in New York to 17.5 percent in jump in their uninsured rate from 7.9 to 9.2 percent for the Texas in 2019. (See Figure 7.) In addition to Latino children, last two years of the data examined (due to data limitations White children (4.9 percent to 5.6 percent) and children it is not yet possible to do a three-year look). This increase whose race is recorded as “Other”9 also saw statistically is very troubling as Latino children already have some of the significant increases (6.0 percent to 6.9 percent for the latter) highest uninsured rates nationally. (See Figure 6.) However, in the uninsured rate. American Indian/Alaska Native children there is considerable state variability. Of the top 10 states continue to have the highest uninsured rates by race. (See with the highest number of Latino children, the uninsured Figure 6.) 8 children’s uninsured rate jumps CCF.GEORGETOWN.EDU October 2020 Figure 6. Children’s Uninsured Rate by Race and Ethnicity, 2017-2019 13.8% 12.9% 2017 2019 9.2%* 7.9% 6.9%* 6.0% 5.6%* 4.9% 4.6% 4.6% 4.4% 4.0% Black/African WhiteAmericanAsian/ OtherHispanic/ AmericanIndian/Alaska Native Hawaiian/Latino NativePacific Islander Source: Georgetown University Center for Children and Families analysis of the U.S. Census 2017-2019 American Community Survey (ACS), Tables C27001A-I. * Change is significant at the 90% confidence level relative to the prior year indicated. Note: Hispanic/Latino refers to a person’s ethnicity, therefore Hispanic individuals may be of any race. Figure 7. Latino Children’s Uninsured Rate for the 10 Largest States, 2019 17.5% 15.9% 13.3% National average 10.8% 9.2% 9.6% 7.4% 6.8% 5.6% 4.4% 2.3% New York CaliforniaIllinois New Jersey Colorado FloridaArizona North Georgia Texas Carolina Source: Georgetown University Center for Children and Families analysis of the U.S. Census 2019 American Community Survey (ACS), Table C27001I. Top 10 states with the highest number of Latino children determined using U.S. Census 2019 American Community Survey (ACS) Table C27001I. Note: Hispanic/Latino refers to a person’s ethnicity, therefore Hispanic individuals may be of any race. October 2020 CCF.GEORGETOWN.EDU children’s uninsured rate jumps 9 Children across all income groups examined lost health States that have not expanded Medicaid are falling further insurance. (See Table 5.) The biggest jump occurred for the behind with respect to covering children.11 The uninsured rate poorest children living in families with incomes below 138 for children living in states that had not adopted the ACA’s percent of the federal poverty level; their uninsured rates Medicaid expansion for parents and other adults is almost jumped almost a percentage point from 6.8 percent to 7.7 double that of children living in states that have expanded percent between 2017 and 2019, putting them at parity with Medicaid as of 2019 (8.1 percent in non-expansion states children living in families with incomes just above the poverty versus 4.2 percent in expansion states). level, who in the past have had the highest uninsured rates. Young children under age six saw a statistically significant increase in their uninsured rate from 3.8 percent to 4.7 percent over the three-year period.10 Table 5. Rate of Uninsured Children by Federal Poverty Level, 2017-2019 Poverty Level 2017 2019 0-137% FPL 6.8% 7.7%* 138-250% FPL 6.9% 7.7%* 250% FPL or above 3.2% 3.8%* Source: Georgetown University Center for Children and Families analysis of the U.S. Census 2017-2019 American Community Survey (ACS), Table B27016. *Change is significant at the 90% confidence level relative to the prior year indicated. How many children have lost coverage in 2020? The data presented here are all pre-pandemic. The economic Federal law tied to the COVID-19 public health emergency recession associated with the COVID-19 pandemic has prohibits states from disenrolling children (and others) from caused considerable growth in unemployment. Some Medicaid, cutting eligibility, or making it harder for eligible children are likely losing employer-sponsored insurance children to enroll—which is likely mitigating some of the coverage when their parents lose their jobs, especially as coverage losses in 2020. 15 Today, as Medicaid enrollment permanent layoffs increase; however, many of those losing rises, the disenrollment freeze in particular is an important jobs, at least initially, were likely in positions that did not protection against the losses of coverage seen due to offer employer-sponsored insurance. The best estimate inappropriate terminations of children’s Medicaid coverage available indicates that 2.9 million people under age 65 will in many states over the past three years.16 However, the become uninsured by the end of 2020 as a consequence of disenrollment freeze does not extend to separate state the current recession.12 Of the almost 3 million increase in CHIP programs nor does it address the ongoing “chilling the uninsured, about 300,000 are estimated to be children, effect” on eligible children whose parents are immigrants on top of any increase that may have otherwise occurred and likely fearful of enrolling them in public coverage as in 2020 pre-pandemic.13 While many of these children are a consequence of the public charge regulation and other likely eligible for Medicaid or CHIP, this depends on where hostile actions towards immigrant families. While the precise they live and it is unclear how many of them will enroll. number of children that are becoming uninsured in 2020 will There is no national effort to inform newly unemployed not be known for some time, there is very little chance that families about their public coverage options. Moreover, the number is going in the right direction. the difficulties experienced by many in applying for unemployment benefits may have deterred families from attempting to receive other public benefits.14 10 children’s uninsured rate jumps CCF.GEORGETOWN.EDU October 2020 Conclusion Having health insurance is an essential pre-condition for pandemic. The United States must renew its commitment to children to get the care they need to grow and thrive. Being ensuring that all children have high quality, affordable, and insured leads to better health, educational, and economic comprehensive health coverage. outcomes—both in the short and long term.17 The recent losses of health coverage during the examined period are very troubling as they reverse years of progress in reducing The recent losses of health coverage are the number of uninsured children. And the current COVID-19 very troubling as they reverse years pandemic and associated recession have only made mat- of progress in reducing the number of ters worse. Children, especially those in communities of uninsured children. color, face a host of challenges associated with the eco- nomic, educational, and health impacts of the COVID-19 Methodology Data Sources and Historic Changes to Age Margin of Error Categories for Children The published U.S. Census Bureau data provide a margin of error The data presented in this brief derive from the U.S. Census (potential error bounds for any given estimate) at a 90 percent Bureau’s annual American Community Survey (ACS) as confidence level. All significance testing was conducted using the presented in two sources: 1) Health Insurance Historical Census Bureau’s Statistical Testing Tool. Differences of percent Table HIC-5. Health Insurance Coverage Status and Type of or number estimates (either between groups, coverage sources, Coverage by State – Children Under 19: 2008 to 2019, and 2) or years) that are statistically significant at a confidence level of the Census Bureau’s platform, Data.Census.Gov. 90 percent are marked with an asterisk (*). Georgetown CCF does not take the margin of error into account when ranking states by Where only number estimates are available, percent estimates the number and percent of the uninsured children by state. Minor were computed based on formulas provided in Chapter differences in state rankings may not be statistically significant. 7 and Chapter 8 of the U.S. Census Bureau’s handbook States that have the same number or percent of uninsured “Understanding and Using American Community Survey Data: children are assigned the same ranking. Where estimates are What All Data Users Need to Know” (published July 2018). In combined to produce new estimates, margin of error results order to better align with the current health landscape, the age were computed following formulas in Chapter 8 of the U.S. categories of the ACS health insurance tables were updated in Census Bureau’s handbook “Understanding and Using American 2017 so that the age group for children includes individuals age Community Survey Data: What All Data Users Need to Know” 18 and younger. In 2016 and previous years, the age group for (published July 2018). children included individuals age 17 and younger. Therefore, this report uses the HIC-05 table for analysis of most three- Geographic Location year data trends over the period 2016 to 2019, while using We report regional data as defined by the Census Bureau. The other data tables from Data.Census.Gov for analyses of certain ACS produces single-year estimates for all geographic areas with three-year and two-year trends. a population of 65,000 or more, which includes all regions, states (including the District of Columbia), and some counties. October 2020 CCF.GEORGETOWN.EDU children’s uninsured rate jumps 11 Poverty Status may be accentuated by the absence of state-specific health Data on poverty levels include only those individuals for insurance program names in the ACS. Further, Georgetown CCF whom the poverty status can be determined for the past year. combines children covered by Medicare, TRICARE/military, VA, Therefore, this population is slightly smaller than the total or two or more types of health insurance (including Medicaid in non-institutionalized population of the U.S. (the universe used combination) into the “other” category. Therefore, children with to calculate all other data in the brief). The Census Bureau Medicaid/CHIP in addition to another type of health insurance determines an individual’s poverty status by comparing that are not included in the Medicaid/CHIP total, which would lower person’s income in the past 12 months to poverty thresholds the number and share of children covered by Medicaid. For that account for family size and composition, as well as various more detail on how the ACS defines sources of health insurance types of income. (Note that the Census Bureau’s definition of coverage, see “American Community Survey and Puerto Rico income may vary considerably from how state Medicaid and Community Survey 2019 Subject Definitions” (78). CHIP programs measure income for purposes of determining Demographic Characteristics eligibility due to differences in how income is counted, “Children” are defined as those individuals age 18 and under. household size is determined, and other factors.) The ACS provides one-year health insurance coverage estimates Health Coverage for the following race/ethnicity categories in tables C27001A-I: Data on sources of health insurance coverage are point-in-time (A-White alone, B-Black/African-American, C-American Indian/ estimates that convey whether a person has coverage at the Alaska Native (AI/AN), D-Asian, E- Native Hawaiian/Pacific time of the survey. The Census Bureau provides the following Islander, F- Some other race, G- Two or more races, H-White, categories of coverage for respondents to indicate sources Non-Hispanic or Latino and I-Hispanic or Latino). The Census of health insurance: employer-based health insurance only, Bureau recognizes and reports race and Hispanic origin (i.e. direct purchase health insurance only, Medicare coverage only, ethnicity) as separate and distinct concepts and variables. To Medicaid/means-tested public coverage only (includes CHIP), report on an individual’s race, we merge the data for “Asian TRICARE/military health coverage only, VA health coverage alone” and “Native Hawaiian or other Pacific Islander alone.” In only, two or more types of health insurance coverage, and addition, we report the ACS category “some other race alone” no health insurance coverage. People who indicate Indian and “two or more races” as “other.” Except for “other,” all racial Health Service (IHS) as their only source of health coverage do categories refer to respondents who indicated belonging to only not have comprehensive coverage according to ACS survey one race. As “Hispanic/Latino” refers to a person’s ethnicity, definitions and are therefore considered to be uninsured. Hispanic and non-Hispanic individuals may be of any race. For Individuals can report more than one source of coverage, so more detail on how the ACS defines racial and ethnic groups, coverage sources totals may add to more than 100 percent. see “American Community Survey and Puerto Rico Community Additionally, the ACS estimates are not adjusted to address the Survey 2019 Subject Definitions” (113-118). Medicaid “undercount” often found when surveys are compared to federal and state administrative data. This bias in the data This brief was written by Joan Alker and Alexandra Corcoran. The authors would like to thank Aubrianna Osorio, Allexa Gardner, Edwin Park, Cathy Hope, and Phyllis Jordan of the Center for Children and Families and Jessica Banthin, Senior Fellow at the Urban Institute. Design and layout provided by Nancy Magill. The Georgetown University Center for Children and Families (CCF) is an independent, nonpartisan policy and research center founded in 2005 with a mission to expand and improve high-quality, affordable health coverage for America’s children and families. CCF is based in the McCourt School of Public Policy’s Health Policy Institute. 12 children’s uninsured rate jumps CCF.GEORGETOWN.EDU October 2020 Appendix Table 1. Number of Uninsured Children Under Age 19, 2016-2019 2016 Number 2016 State 2019 Number 2019 State State Uninsured Ranking Uninsured Ranking United States 3,649,000 - 4,375,000 - Alabama 32,000 22 40,000 21 Alaska 20,000 14 18,000 12 Arizona 132,000 47 161,000 47 Arkansas 30,000 20 43,000 23 California 300,000 50 334,000 49 Colorado 57,000 33 73,000 33 Connecticut 23,000 17 27,000 17 Delaware 7,000 4 10,000 5 District of Columbia 4,000 2 3,000 1 Florida 288,000 49 343,000 50 Georgia 179,000 48 197,000 48 Hawaii 8,000 5 9,000 4 Idaho 22,000 16 24,000 16 Illinois 82,000 40 120,000 43 Indiana 99,000 41 119,000 42 Iowa 20,000 14 22,000 14 Kansas 34,000 23 43,000 23 Kentucky 35,000 24 45,000 25 Louisiana 39,000 26 50,000 28 Maine 13,000 10 15,000 8 Maryland 49,000 29 48,000 27 Massachusetts 15,000 12 22,000 14 Michigan 71,000 36 78,000 34 Minnesota 46,000 27 42,000 22 Mississippi 37,000 25 46,000 26 Missouri 71,000 36 95,000 39 Montana 12,000 9 15,000 8 Nebraska 25,000 18 28,000 18 Nevada 50,000 30 58,000 31 New Hampshire 8,000 5 10,000 5 New Jersey 78,000 38 88,000 38 New Mexico 28,000 19 29,000 19 New York 113,000 44 101,000 41 North Carolina 115,000 45 142,000 46 North Dakota 15,000 12 15,000 8 Ohio 104,000 43 131,000 45 Oklahoma 79,000 39 86,000 37 Oregon 31,000 21 38,000 20 Pennsylvania 126,000 46 128,000 44 Rhode Island 5,000 3 4,000 3 South Carolina 50,000 30 69,000 32 South Dakota 11,000 8 18,000 12 Tennessee 58,000 34 80,000 35 Texas 752,000 51 995,000 51 Utah 59,000 35 82,000 36 Vermont 2,000 1 3,000 1 Virginia 99,000 41 97,000 40 Washington 46,000 27 54,000 30 West Virginia 9,000 7 13,000 7 Wisconsin 50,000 30 51,000 29 Wyoming 13,000 10 15,000 8 Source: Georgetown University Center for Children and Families analysis of the U.S. Census Bureau American Community Survey (ACS) Table HIC-5, Health Insurance Coverage Status and Type of Coverage by State - Children Under 19: 2008 to 2019, Health Insurance Historical Tables. October 2020 CCF.GEORGETOWN.EDU children’s uninsured rate jumps 13 Appendix Table 2. Percent of Uninsured Children Under 19, 2016-2019 2016 Percent 2016 State 2019 Percent 2019 State State Uninsured Ranking Uninsured Ranking United States 4.7 - 5.7 - Alabama 2.7 9 3.5 12 Alaska 10.3 51 9.4 49 Arizona 7.6 46 9.2 48 Arkansas 4.0 26 5.9 36 California 3.1 13 3.6 15 Colorado 4.3 27 5.5 29 Connecticut 2.8 12 3.5 12 Delaware 3.1 13 4.8 24 District of Columbia 3.1 13 2.0 3 Florida 6.6 43 7.6 42 Georgia 6.7 44 7.4 41 Hawaii 2.5 5 2.8 6 Idaho 4.9 36 5.0 27 Illinois 2.6 7 4.0 18 Indiana 5.9 41 7.1 40 Iowa 2.6 7 2.9 7 Kansas 4.5 30 5.8 33 Kentucky 3.3 17 4.3 20 Louisiana 3.3 17 4.4 22 Maine 4.8 33 5.6 30 Maryland 3.4 19 3.4 10 Massachusetts 1.0 1 1.5 1 Michigan 3.1 13 3.4 10 Minnesota 3.4 19 3.1 8 Mississippi 4.8 33 6.1 37 Missouri 4.8 33 6.5 39 Montana 4.9 36 6.2 38 Nebraska 5.1 39 5.7 31 Nevada 7.0 45 8.0 45 New Hampshire 2.7 9 3.7 16 New Jersey 3.7 22 4.3 20 New Mexico 5.3 40 5.7 31 New York 2.5 5 2.4 5 North Carolina 4.7 31 5.8 33 North Dakota 8.0 48 7.8 43 Ohio 3.8 25 4.8 24 Oklahoma 7.7 47 8.6 47 Oregon 3.4 19 4.1 19 Pennsylvania 4.4 29 4.6 23 Rhode Island 2.2 3 1.9 2 South Carolina 4.3 27 5.8 33 South Dakota 4.7 31 7.8 43 Tennessee 3.7 22 5.0 27 Texas 9.8 50 12.7 51 Utah 6.0 42 8.3 46 Vermont 1.5 2 2.1 4 Virginia 5.0 38 4.9 26 Washington 2.7 9 3.1 8 West Virginia 2.3 4 3.5 12 Wisconsin 3.7 22 3.8 17 Wyoming 8.8 49 10.6 50 Source: Georgetown University Center for Children and Families analysis of the U.S. Census Bureau American Community Survey (ACS) Table HIC-5, Health Insurance Coverage Status and Type of Coverage by State - Children Under 19: 2008 to 2019, Health Insurance Historical Tables. 14 children’s uninsured rate jumps CCF.GEORGETOWN.EDU October 2020 Appendix Table 3. Change in the Number of Uninsured Children Under 19, 2016-2019 2016 Number 2019 Number 2016-2019 Change in 2016-2019 State Uninsured Uninsured Number of Uninsured Percent Change United States 3,649,000 4,375,000 726,000 * 19.9% Alabama 32,000 40,000 8,000 * 25.0% Alaska 20,000 18,000 -2,000 -10.0% Arizona 132,000 161,000 29,000 * 22.0% Arkansas 30,000 43,000 13,000 * 43.3% California 300,000 334,000 34,000 * 11.3% Colorado 57,000 73,000 16,000 * 28.1% Connecticut 23,000 27,000 4,000 17.4% Delaware 7,000 10,000 3,000 42.9% District of Columbia 4,000 3,000 -1,000 -25.0% Florida 288,000 343,000 55,000 * 19.1% Georgia 179,000 197,000 18,000 10.1% Hawaii 8,000 9,000 1,000 12.5% Idaho 22,000 24,000 2,000 9.1% Illinois 82,000 120,000 38,000 * 46.3% Indiana 99,000 119,000 20,000 * 20.2% Iowa 20,000 22,000 2,000 10.0% Kansas 34,000 43,000 9,000 * 26.5% Kentucky 35,000 45,000 10,000 * 28.6% Louisiana 39,000 50,000 11,000 * 28.2% Maine 13,000 15,000 2,000 15.4% Maryland 49,000 48,000 -1,000 -2.0% Massachusetts 15,000 22,000 7,000 * 46.7% Michigan 71,000 78,000 7,000 9.9% Minnesota 46,000 42,000 -4,000 -8.7% Mississippi 37,000 46,000 9,000 * 24.3% Missouri 71,000 95,000 24,000 * 33.8% Montana 12,000 15,000 3,000 * 25.0% Nebraska 25,000 28,000 3,000 12.0% Nevada 50,000 58,000 8,000 * 16.0% New Hampshire 8,000 10,000 2,000 25.0% New Jersey 78,000 88,000 10,000 12.8% New Mexico 28,000 29,000 1,000 3.6% New York 113,000 101,000 -12,000 * -10.6% North Carolina 115,000 142,000 27,000 * 23.5% North Dakota 15,000 15,000 - - Ohio 104,000 131,000 27,000 * 26.0% Oklahoma 79,000 86,000 7,000 8.9% Oregon 31,000 38,000 7,000 * 22.6% Pennsylvania 126,000 128,000 2,000 1.6% Rhode Island 5,000 4,000 -1,000 -20.0% South Carolina 50,000 69,000 19,000 * 38.0% South Dakota 11,000 18,000 7,000 * 63.6% Tennessee 58,000 80,000 22,000 * 37.9% Texas 752,000 995,000 243,000 * 32.3% Utah 59,000 82,000 23,000 * 39.0% Vermont 2,000 3,000 1,000 50.0% Virginia 99,000 97,000 -2,000 -2.0% Washington 46,000 54,000 8,000 * 17.4% West Virginia 9,000 13,000 4,000 * 44.4% Wisconsin 50,000 51,000 1,000 2.0% Wyoming 13,000 15,000 2,000 15.4% Source: Georgetown University Center for Children and Families analysis of the U.S. Census Bureau American Community Survey (ACS) Table HIC-5, Health Insurance Coverage Status and Type of Coverage by State - Children Under 19: 2008 to 2019, Health Insurance Historical Tables. *Change is significant at the 90% confidence level relative to the prior year indicated. October 2020 CCF.GEORGETOWN.EDU children’s uninsured rate jumps 15 Appendix Table 4. Change in the Rate of Uninsured Children Under 19, 2016-2019 2016 Percent 2019 Percent 2016-2019 State Uninsured Uninsured Rate Change United States 4.7 5.7 1.0 * Alabama 2.7 3.5 0.8 * Alaska 10.3 9.4 -0.9 Arizona 7.6 9.2 1.6 * Arkansas 4.0 5.9 1.9 * California 3.1 3.6 0.5 * Colorado 4.3 5.5 1.2 * Connecticut 2.8 3.5 0.7 Delaware 3.1 4.8 1.7 * District of Columbia 3.1 2.0 -1.1 Florida 6.6 7.6 1.0 * Georgia 6.7 7.4 0.7 Hawaii 2.5 2.8 0.3 Idaho 4.9 5.0 0.1 Illinois 2.6 4.0 1.4 * Indiana 5.9 7.1 1.2 * Iowa 2.6 2.9 0.3 Kansas 4.5 5.8 1.3 * Kentucky 3.3 4.3 1.0 * Louisiana 3.3 4.4 1.1 * Maine 4.8 5.6 0.8 Maryland 3.4 3.4 - Massachusetts 1.0 1.5 0.5 * Michigan 3.1 3.4 0.3 Minnesota 3.4 3.1 -0.3 Mississippi 4.8 6.1 1.3 * Missouri 4.8 6.5 1.7 * Montana 4.9 6.2 1.3 * Nebraska 5.1 5.7 0.6 Nevada 7.0 8.0 1.0 New Hampshire 2.7 3.7 1.0 New Jersey 3.7 4.3 0.6 * New Mexico 5.3 5.7 0.4 New York 2.5 2.4 -0.1 North Carolina 4.7 5.8 1.1 * North Dakota 8.0 7.8 -0.2 Ohio 3.8 4.8 1.0 * Oklahoma 7.7 8.6 0.9 * Oregon 3.4 4.1 0.7 Pennsylvania 4.4 4.6 0.2 Rhode Island 2.2 1.9 -0.3 South Carolina 4.3 5.8 1.5 * South Dakota 4.7 7.8 3.1 * Tennessee 3.7 5.0 1.3 * Texas 9.8 12.7 2.9 * Utah 6.0 8.3 2.3 * Vermont 1.5 2.1 0.6 Virginia 5.0 4.9 -0.1 Washington 2.7 3.1 0.4 West Virginia 2.3 3.5 1.2 * Wisconsin 3.7 3.8 0.1 Wyoming 8.8 10.6 1.8 Source: Georgetown University Center for Children and Families analysis of the U.S. Census Bureau American Community Survey (ACS) Table HIC-5, Health Insurance Coverage Status and Type of Coverage by State - Children Under 19: 2008 to 2019, Health Insurance Historical Tables. *Change is significant at the 90% confidence level relative to the prior year indicated. 16 children’s uninsured rate jumps CCF.GEORGETOWN.EDU October 2020 Appendix Table 5. Top 20 Counties with the Highest Number of Uninsured Children, 2019 Number of Percent of Total Child County Rank County Uninsured Children Population (descending) Children Uninsured United States 77,350,000 4,375,000 5.7% - Harris County, Texas 1,303,000 195,000 15.0% 1 Dallas County, Texas 717,000 122,000 17.0% 2 Maricopa County, Arizona 1,114,000 101,000 9.1% 3 Los Angeles County, California 2,268,000 91,000 4.0% 4 Tarrant County, Texas 578,000 67,000 11.6% 5 Cook County, Illinois 1,171,000 54,000 4.6% 6 Hidalgo County, Texas 294,000 49,000 16.7% 7 Bexar County, Texas 535,000 48,000 9.0% 8 Broward County, Florida 433,000 46,000 10.6% 9 Clark County, Nevada 547,000 44,000 8.0% 10 Miami-Dade County, Florida 581,000 43,000 7.4% 11 Travis County, Texas 285,000 35,000 12.3% 12 San Diego County, California 757,000 30,000 4.0% 13 El Paso County, Texas 238,000 30,000 12.6% 14 Orange County, California 730,000 29,000 4.0% 15 Gwinnett County, Georgia 260,000 29,000 11.2% 16 Salt Lake County, Utah 325,000 28,000 8.6% 17 Palm Beach County, Florida 302,000 27,000 8.9% 18 San Bernardino County, California 599,000 26,000 4.3% 19 Riverside County, California 649,000 25,000 3.9% 20 Source: Georgetown University Center for Children and Families analysis of the U.S. Census Bureau 2019 American Community Survey (ACS) data, Table B27010. Data may not sum due to rounding. October 2020 CCF.GEORGETOWN.EDU children’s uninsured rate jumps 17 Endnotes 1 Alker, J. and Pham, O., “Nation’s Uninsured Rate for Children Drops Children and Families, SayAhh! Blog, February 18, 2020, available at to Another Historic Low in 2016,” Georgetown University Center https://ccf.georgetown.edu/2020/02/18/child-enrollment-in-medicaid- for Children and Families, October 2017, available at https://ccf. and-chip-remains-down-in-2019/#:~:text=As%20of%20October%20 georgetown.edu/2017/10/22/nationwide-rate-of-uninsured-children- 2019%2C%20the,enrollment%20data%20posted%20by%20CMS. reaches-historic-low/#:~:text=Nationwide%2095.5%20percent%20 9 Our analysis merges the American Community Survey estimates of of%20children,the%20ACA%20was%20fully%20implemented. children of “two or more races” and “some other race” into “Other.” 2 Rae, M., Copeland, R., and Cox, C., “Tracking the Rise in Premium The Census Bureau defines the category of “some other race” as: Contributions and Cost-sharing for Families with Large Employer “Includes all other responses not included in the ‘White,’ ‘Black Coverage,” Peterson-KFF Health System Tracker, August 14, 2019, or African American,’ ‘American Indian or Alaska Native,’ ‘Asian,’ available at https://www.healthsystemtracker.org/brief/tracking-the- and ‘Native Hawaiian or Other Pacific Islander’ race categories […] rise-in-premium-contributions-and-cost-sharing-for-families-with-large- Respondents reporting entries such as multiracial, mixed, interracial, employer-coverage/. or a Hispanic, Latino, or Spanish group (for example, Mexican, 3 Artiga, S. and Ubri, P., “Key Issues in Children’s Health Coverage” Puerto Rican, Cuban, or Spanish) in response to the race question Kaiser Family Foundation, February 2017, available at https://www.kff. are included in this category.” See “American Community Survey and org/medicaid/issue-brief/key-issues-in-childrens-health-coverage/. Puerto Rico Community Survey 2019 Subject Definitions” (District of Columbia: US Census Bureau), available at https://www2.census. 4 Unless otherwise noted, all data in this report is based on a gov/programs-surveys/acs/tech_docs/subject_definitions/2019_ Georgetown University Center for Children and Families analysis of the ACSSubjectDefinitions.pdf. U.S. Census Bureau American Community Survey data for the time period 2016 to 2019. Due to a change in the ACS’s age categorization 10 The ACS updated its age categories in 2017, changing the upper for children in 2017, a few data points are presented as two-year bound of the child population from 18 years of age to 19 years of trends, from 2017 to 2019. Please see the methodology for more age. Consequently, at this time, it is only possible to analyze a three- information. year trend in the uninsured rate for children under six. Please see the methodology section for more detail. A separate analysis from 5 “CivilianUnemployment Rate,” Bureau of Labor Statistics, available Georgetown CCF will provide state-by-state data for the under six group. at https://www.bls.gov/charts/employment-situation/civilian- unemployment-rate.htm. For more on current challenges facing families A forthcoming analysis from Georgetown CCF will explore this trend in 11 see “Tracking the COVID-19 Recession’s Effects on Food, Housing, more detail. and Employment Hardships,” September 2020, available at https:// 12 Banthin, J. et al., “Changes in Health Insurance Coverage Due to the www.cbpp.org/research/poverty-and-inequality/tracking-the-covid-19- COVID-19 Recession: Preliminary Estimates Using Microsimulation,” recessions-effects-on-food-housing-and. Urban Institute, July 2020, available at https://www.urban.org/sites/ 6 The Trump administration reduced funding for Navigator programs default/files/publication/102552/changes-in-health-insurance-coverage- from $63 million in 2016 to $10 million in 2018. Additionally, the funds due-to-the-covid-19-recession_4.pdf. set aside for outreach and advertising efforts during open enrollment 13 Unpublished tabulations from Banthin, J. et al., op. cit. periods suffered a 90 percent reduction. See Pollitz, K., Tolbert, J., 14 Evermore, M., “Long Lines for Unemployment: How Did We Get and Diaz, M., “Data Note: Limited Navigator Funding for Federal Here and What Do We Do Now?” National Employment Law Center, Marketplace States,” Kaiser Family Foundation, November 2019, April 2020, available at https://www.nelp.org/publication/long-lines- available at https://www.kff.org/health-reform/issue-brief/data-note- for-unemployment-how-did-we-get-here-and-what-do-we-do-now/; further-reductions-in-navigator-funding-for-federal-marketplace-states/; Roll, S., and Grinstein-Weiss, M., “Did CARES Act Benefits Reach Pollitz, K., Tolbert, J., Hamel, L., and Kearney, A., “Consumer Assistance Vulnerable Americans? Evidence from a National Survey,” The in Health Insurance: Evidence of Impact and Unmet Need,” Kaiser Brookings Institution, August 2020, available at https://www.brookings. Family Foundation, August 2020, available at https://www.kff.org/report- edu/research/did-cares-act-benefits-reach-vulnerable-americans- section/consumer-assistance-in-health-insurance-evidence-of-impact- evidence-from-a-national-survey/; and Akhtar, A. and Lichtenberg, N., and-unmet-need-issue-brief/; and Hoppe, O., “Affordable Care Act “A State-by-State Breakdown of Failures in Unemployment Systems Navigators: Lack of Funding Leads to Consumer Confusion, Decreased Across the US During the Pandemic,” Business Insider, September Enrollment,” Georgetown University Center for Health Insurance 9, 2020, available at https://www.businessinsider.com/how-states- Reform, CHIRblog, January 18, 2019, available at http://chirblog.org/ unemployment-insurance-programs-ended-in-disaster-2020-9. lack-of-navigator-funding-leads-confusion-decreased-enrollment/. 15 Brooks, T. and Schneider, A., “The Families First Coronavirus 7 Haley, J. et al., “One in Five Adults in Immigrant Families with Children Response Act: Medicaid and CHIP Provisions Explained,” Georgetown Reported Chilling Effects on Public Benefit Receipt in 2019,” Urban University Center for Children and Families, March 2020, available Institute, June 2020, available at https://www.urban.org/research/ at https://ccf.georgetown.edu/2020/03/22/families-first-coronavirus- publication/one-five-adults-immigrant-families-children-reported- response-act-medicaid-and-chip-provisions-explained/. chilling-effects-public-benefit-receipt-2019. 16 Brooks, T., Park, E., and Roygardner, L., op. cit. 8 Brooks, T., Park, E., and Roygardner, L., “Medicaid and CHIP 17 Wagnerman, K., Chester, A., and Alker, J., “Medicaid Is A Smart Enrollment Decline Suggests the Child Uninsured Rate May Rise Again,” Investment in Children,” Georgetown University Center for Children Georgetown University Center for Children and Families, May 2019, and Families, March 2017, available at https://ccf.georgetown. available at https://ccf.georgetown.edu/2019/05/28/medicaid-and- edu/2017/03/13/medicaid-is-a-smart-investment-in-children/. chip-enrollment-decline/; Brooks, T., “Child Enrollment in Medicaid and CHIP Remains Down in 2019,” Georgetown University Center for 18 children’s uninsured rate jumps CCF.GEORGETOWN.EDU October 2020 Georgetown University Center for Children and Families McCourt School of Public Policy 600 New Jersey Avenue, NW Washington, DC 20001 Phone: (202) 687-0880 Email: childhealth@georgetown.edu ccf.georgetown.edu/blog/ facebook.com/georgetownccf twitter.com/georgetownccf October 2020 CCF.GEORGETOWN.EDU children’s uninsured rate jumps 19