Children Are Left Behind When States Fail to Expand Medicaid by Adam Searing, Alexandra Corcoran, and Joan Alker Key Findings Introduction zz Growing numbers of uninsured children are Since its passage in 2010, the Affordable Care Act concentrating in states that have not expanded (ACA) has played a critical role in lowering the rate Medicaid. Between 2016 and 2019, the child of uninsured children in America. A key part of the uninsured rate in non-expansion states grew at ACA’s success in this area was the Act’s expansion nearly three times the rate of expansion states. Non- of Medicaid to more working-age adults. In 2016, just expansion states saw their child uninsured rate jump two years after the majority of states implemented the from 6.5 percent to 8.1 percent during the period Affordable Care Act’s Medicaid expansion, the nation’s examined while expansion states saw it increase from uninsured rate for children reached a historic low of 3.5 percent to 4.1 percent (see figure 3 ). Moreover, 4.7 percent. As states extended Medicaid eligibility two non-expansion states, Texas and Florida, were to adults up to 138 percent of the Federal Poverty responsible for 41 percent of the coverage losses for Level (FPL), enrolling newly eligible parents created a children over the three-year period.1 “welcome mat” enrollment effect for children—many of zz While Medicaid expansion was designed to help whom were already eligible for health coverage but not uninsured adults who could not afford private enrolled in a plan.4 This meant the child uninsured rate insurance, the policy change also benefits children. declined in tandem with the non-elderly uninsured rate When parents gain coverage, they are more likely to as parents signed themselves and their entire family up access the supports they need to be a healthy and for coverage. effective parent, more likely to enroll their children in Medicaid expansion has not only reduced the number “whole family” health coverage, and more likely to take of uninsured children but also led to improved prenatal their children to the doctor.2 In short, covering parents and maternal health, higher preventative care use for also means covering children, protecting families from children, and decreased incidence of child neglect economic strains associated with medical debt, and in the states that chose to expand.5 These coverage laying the groundwork for optimal child development. and health benefits are not uniform across the states. zz Extending access to Medicaid coverage for adults As of January 2021, nearly eleven years after the benefits the whole family by providing continuous passage of the ACA and seven years after Medicaid access to care and improving reproductive expansion officially took effect in most states, 12 health. Medicaid expansion has been shown to states have yet to accept federal funding to expand improve preconception and prenatal care, including Medicaid coverage to parents and other adults. As a increased use of folic acid supplements, critical health consequence, many families in these states do not screenings, and mental health services. Expansion have access to affordable coverage, a high share of is also associated with lower maternal and infant children remain uninsured, and these health benefits mortality rates.3 for families go unrealized. February 2021 CCF.GEORGETOWN.EDU children and medicaid expansion 1 Making matters worse, since 2016 the nation has reversed majority of uninsured children live in non-expansion states. its historic progress in covering children, and the rate of Expanding Medicaid in the 12 remaining states is a crucial uninsured children rose by a full percentage point to 5.7 step to put our nation back on track for children’s health and percent in 2019. This increase is driven in large part by the move closer to the day when all children in the U.S. have states that have still not expanded Medicaid. Today, while access to the health care they need to succeed. the majority of all children live in expansion states, the When parents have access to health coverage, they are more likely to sign up their children for health coverage. Research has clearly shown that when parents gain health In 2019, states that continued to refuse federal funds for insurance coverage, their children are more likely to have Medicaid expansion had almost twice the rate of uninsured health coverage too. This effect is known as the “welcome children than states that did expand Medicaid (8.1 percent in mat” effect.6 Although Medicaid expansion extends non-expansion states compared to 4.1 percent in expansion coverage to adults, Medicaid and CHIP participation rates states) (see figure 1). And, only two non-expansion states had for children are consistently higher in expansion states than child uninsured rates lower than 5.0 percent (see figure 2). non-expansion states.7 Uninsured children are often eligible but not enrolled in state Medicaid and CHIP programs, and Figure 1. Children’s Uninsured Rate by Medicaid outreach efforts for adult enrollment allow children to be Expansion Status, 2019 easily enrolled as well.8 9.0% 8.1% 8.0% 7.0% 6.0% 5.0% 4.1% 4.0% 3.0% 2.0% 1.0% 0.0% Expansion Non-Expansion Source: Georgetown University Center for Children and Families analysis of Table HIC-5, Health Insurance Coverage Status and Type of Coverage by State - Children Under 19: 2008 to 2019, Health Insurance Historical Tables, U.S. Census Bureau American Community Survey (ACS). Maine and Virginia excluded from analysis in this chart. 2 children and medicaid expansion CCF.GEORGETOWN.EDU February 2021 Figure 2. Rate of Uninsured Children in Medicaid Expansion States and Non-Expansion States, 2019 Texas 12.7 Wyoming 10.6 Alaska 9.4 Arizona 9.2 Oklahoma* 8.6 Utah* 8.3 Nevada 8.0 South Dakota 7.8 North Dakota 7.8 Florida 7.6 Georgia 7.4 Indiana 7.1 Missouri* 6.5 Montana 6.2 Mississippi 6.1 Arkansas 5.9 Non-Expansion South Carolina 5.8 States North Carolina 5.8 Kansas Expansion 5.8 States New Mexico 5.7 Nebraska* 5.7 United States 5.7 Maine 5.6 * Idaho began expansion Colorado 5.5 enrollment in November Tennessee 5.0 2019. Nebraska and Utah Idaho* 5.0 implemented Medicaid Virginia 4.9 expansion in 2020, after this data was collected. Ohio 4.8 Missouri and Oklahoma plan Delaware 4.8 to implement expansion in Pennsylvania 4.6 2021. Louisiana 4.4 New Jersey 4.3 Kentucky 4.3 Oregon 4.1 Illinois 4.0 Source: Georgetown University Center for Children Wisconsin 3.8 and Families analysis of Table New Hampshire 3.7 HIC-5, Health Insurance California 3.6 Coverage Status and Type of West Virginia 3.5 Coverage by State - Children Connecticut 3.5 Under 19: 2008 to 2019, Health Insurance Historical Alabama 3.5 Tables, U.S. Census Bureau Michigan 3.4 American Community Survey Maryland 3.4 (ACS). Washington 3.1 Minnesota 3.1 Iowa 2.9 Hawaii 2.8 New York 2.4 Vermont 2.1 District of Columbia 2.0 Rhode Island 1.9 Massachusettes 1.5 0% 2.0% 4.0% 6.0% 8.0% 10.0% 12.0%14.0% February 2021 CCF.GEORGETOWN.EDU children and medicaid expansion 3 Medicaid expansion states do a better job providing healthcare for children. In addition to lowering the barriers to enrolling children in Beyond the preconception, prenatal, and postpartum health coverage, extending access to Medicaid coverage periods, extending Medicaid coverage to parents increases for adults benefits the whole family by providing continuous families’ interaction with the healthcare system and access to care and improving women’s reproductive health. improves their financial stability leading to a multitude of First, Medicaid expansion improves preconception and benefits for children. After Louisiana expanded Medicaid in prenatal care uptake, thus fostering healthier pregnancies 2016, the share of poor children (children in families whose and births. Data from the first five years of Medicaid income was below 100 percent of the federal poverty level expansion implementation show that extending coverage FPL) who had at least one well-child checkup increased increased the likelihood that future parents would seek out while the share of poor children receiving preventative care preconception counseling, take folic acid supplements, and in Louisiana’s non-expansion neighbors, Mississippi and use effective contraception during the postpartum period.9 Texas, decreased.16 For children below the age of six, the In Oregon, likely due to increased preconception care for improved familial financial stability that comes with Medicaid low-income women, expansion significantly decreased the expansion is associated with a significant decline in child probability of low birth weight and preterm births.10 neglect.17 Researchers estimate that if non-expansion states extended coverage, over 40,000 cases of child neglect After birth, continuous coverage in expansion states per year could be prevented.18 Medicaid expansion states provides access to critical screenings, and mental health also saw a larger drop in their high school dropout rates services during a longer postpartum period. In non- than non-expansion states when compared to a pre-ACA expansion states, pregnancy-based Medicaid coverage ends baseline.19 Continuous coverage for parents paves the way 60 days after birth for most women.11 In expansion states, for children to access needed healthcare and for families to however, the higher income eligibility limit allows more grow and thrive together. individuals to maintain their access to health care through Medicaid and reduces churn between public coverage and uninsurance.12 Consequently the uninsured rate for women who had given birth in the prior 12 months was 3.2 times higher in non-expansion states than it was in expansion states in 2017.13 In the expansion state of Colorado, women who had given birth in the past six months, especially those with conditions that put them at high risk of severe maternal morbidity, were more likely to access postpartum health screenings than their peers in Utah (which had not expanded Medicaid at the time of the study).14 Coverage also gives postpartum women full access to mental health care, a crucial service given that postpartum depression impairs bonding between parent and child during the critical early years and can last up to three years after a child’s birth.15 4 children and medicaid expansion CCF.GEORGETOWN.EDU February 2021 Growth in the child uninsured rate has been led by Medicaid non-expansion states. Between 2016 and 2019, while the uninsured rate for children time period while states that had expanded Medicaid saw a climbed in states across the nation, in non-expansion states jump from 3.5 percent to 4.1 percent (0.6 percentage points) the child uninsured rate grew nearly three times as fast as (see figure 3). Further, two non-expansion states, Texas and in expansion states. Non-expansion states saw a jump from Florida, were responsible for 41 percent of the coverage 6.5 percent to 8.1 percent (1.6 percentage points) during the losses over the three-year period.20 Figure 3. Children’s Uninsured Rate Increased at a Faster Pace in Non-Expansion States, 2016 to 2019 Non-expansion states 6.5% 8.1%* Expansion states 3.5% 4.1%* 0%1%2%3%4%5% 6%7%8% 9% Source: Georgetown University Center for Children and Families analysis of Table HIC-5, Health Insurance Coverage Status and Type of Coverage by State - Children Under 19: 2008 to 2019, Health Insurance Historical Tables, U.S. Census Bureau American Community Survey (ACS). * Change is significant at the 90% confidence level relative to the prior year indicated. Twelve states still have not expanded Medicaid, primarily in the South. As of December 2020, 39 states (including the District of be available until at least mid-2021. In those states that Columbia) have expanded Medicaid thereby extending have refused to expand Medicaid, many parents fall into coverage to all adults up to 138 percent FPL ($17,609 for a “coverage gap”: their income is too high to qualify for an individual or $29,974 for a family of three). There are 12 Medicaid under their state’s section 1931 eligibility limit, but states still refusing to accept the federal funding available for too low to qualify for subsidized marketplace coverage (see Medicaid expansion. Two states, Oklahoma and Missouri, table 1). are in the process of implementing voter-passed ballot initiatives expanding Medicaid, although coverage will not February 2021 CCF.GEORGETOWN.EDU children and medicaid expansion 5 Table 1. Parental Eligibility Limits in Non-Expansion States Section 1931 Eligibility Limit for Eligibility Limit in Dollars for a State Low-Income Parents (% of FPL) Family of Three Alabama 18% $3,910 Florida 31% $6,733 Georgia 35% $7,602 Kansas 38% $8,254 Mississippi 26% $5,647 Missouri* 21% $4,561 North Carolina 41% $8,905 Oklahoma* 41% $8,905 South Carolina 67% $14,552 South Dakota 48% $10,426 Tennessee 94% $20,417 Texas 17% $3,692 Wisconsin 100% $21,720 Wyoming 53% $11,512 Source: Source: T. Brooks, et al., “Medicaid and CHIP Eligibility, Enrollment and Cost Sharing Policies as of January 2020: Findings from a 50-State Survey,” Georgetown University Center for Children and Families and the Kaiser Family Foundation (March 2020), available at http://files. kff.org/attachment/Report-Medicaid-and-CHIP-Eligibility,-Enrollment-and-Cost-Sharing-Policies-as-of-January-2020.pdf. * Missouri and Oklahoma voters opted to expand Medicaid, but as of the publication of this brief the states had yet to implement. With Missouri and Oklahoma set to implement voter-approved Medicaid expansion this year, there are 12 states, largely in the South, still refusing the federal funding available for expansion (see figure 4). Almost three-quarters of adults who would gain coverage if the final 12 holdout states expanded Medicaid coverage live in the “big four” southern states: Texas, Florida, Georgia, and North Carolina. And 92 percent of people in the Medicaid “coverage gap” now live in the South.21 Figure 4. Medicaid Expansion Status as of January 2021 The 12 states still refusing funding to expand Medicaid are mostly in the South. Adopted and implemented Adopted but not implemented Not adopted Source: Kaiser Family Foundation 6 children and medicaid expansion CCF.GEORGETOWN.EDU February 2021 The 12 holdout non-expansion states account for only 37.4 percent of the overall child population, but over half of the uninsured child population (53.8 percent) (see figure 5). More than one-third of uninsured children in the nation live in the “big four” of those non-expansion states: Texas, Florida, Georgia, and North Carolina (see figure 5). Figure 5. Uninsured Children in the United States Non-expansion More than Texas More than states 22.7% 53.8% Florida Expansion of all uninsured Uninsured 7.8% of uninsured states children in children live in Georgia children live in 46.2% other states non-expansion 4.5% just 4 of the 61.7% states North non-expansion Carolina states 3.2% Source: Georgetown University Center for Children and Families analysis of Table HIC-5, Health Insurance Coverage Status and Type of Coverage by State - Children Under 19: 2008 to 2019, Health Insurance Historical Tables, U.S. Census Bureau American Community Survey (ACS). Conclusion The concentration of uninsured children in states that have Even though Medicaid expansion is directed at adults, the large not expanded Medicaid is a troubling and growing trend. number of parents who gain coverage when states accept the Data presented in this report are all pre-pandemic, meaning expansion means that children benefit as well. When parents that many more children have likely lost insurance over the gain coverage, they are more likely to access the supports they past year.22 Parents, and consequently their children, living need to be a healthy and effective parent, more likely to enroll in non-expansion states will struggle more to find affordable their children in health coverage, and more likely to take their coverage and care than their counterparts in expansion children to the doctor.23 In short, covering parents also means states. improving the lives of children. This brief was written by Adam Searing, Alexandra Corcoran, and Joan Alker. The authors would like to thank Aubrianna Osorio and Catherine Hope of the Center for Children and Families for their contributions. 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. February 2021 CCF.GEORGETOWN.EDU children and medicaid expansion 7 Methodology Data Sources and Historic Changes to Age “Understanding and Using American Community Survey Categories for Children Data: What All Data Users Need to Know” (published July This brief was compiled using publicly available data from the 2018). All significance testing was conducted using the Census U.S. Census Bureau’s annual American Community Survey Bureau’s Statistical Testing Tool. Differences of percent or (ACS). The data come from two sources: 1) Health Insurance number estimates (either between groups, coverage sources, Historical Table HIC-5: Health Insurance Coverage Status and or years) that are statistically significant at a confidence level Type of Coverage by State—Children Under 19: 2008 to 2019. 2) of 90 percent are marked with an asterisk (*). Georgetown CCF the detailed tables available on Data.Census.Gov. does not take the margin of error into account when ordering Where only number estimates are available, percent estimates states by the number and percent of the uninsured children were computed using the formulas provided in Chapter (figure 2). 7 and Chapter 8 of the U.S. Census Bureau’s handbook, Geographic Location “Understanding and Using American Community Survey Data: What All Data Users Need to Know” (published July 2018). We report regional data as defined by the Census Bureau. The ACS produces single-year estimates for all geographic areas with In order to better align with the current health landscape, the a population of 65,000 or more. age categories of the ACS health insurance detailed tables were updated in 2017 so that the age group for children includes Health Coverage individuals ages 18 and younger. In 2016 and previous years, the Data on sources of health insurance coverage are point-in-time age group for children included individuals ages 17 and younger. estimates that convey whether a person has coverage at the Therefore, this report uses the HIC-5 table for analysis of trends time of the survey. The Census Bureau provides the following over the three-year period 2016-2019. categories of coverage for respondents to indicate sources of health insurance: employer-based health insurance only, Expansion Status direct purchase health insurance only, Medicare coverage only, Expansion status is determined by whether or not a state has Medicaid/means-tested public coverage only (includes CHIP), accepted federal funds to expand Medicaid to adults up to 138 TRICARE/military health coverage only, VA health coverage only, percent of the Federal Poverty Level. Idaho began expansion two or more types of health insurance, and no health insurance enrollment in November 2019 and Oklahoma and Nebraska coverage. People who indicate Indian Health Services (IHS) as implemented expansion in 2020. Missouri and Oklahoma both their only source of health coverage do not have comprehensive passed Medicaid expansion by ballot initiative in 2020, but coverage according to ACS survey definitions and are therefore had not implemented the program at the time that the data considered to be uninsured. For more detail on how the ACS was collected (2016-2019). Consequently, these five states are defines sources of health insurance coverage, see “American categorized as non-expansion states in this analysis. Both Maine Community Survey and Puerto Rico Community Survey 2019 and Virginia implemented Medicaid expansion between 2016 Subject Definitions” (78). and 2019. For consistency’s sake, these two states are excluded from the analysis when determining change over time (figure 1, Demographic Characteristics figure 3). However, they are categorized as expansion states and “Children” are defined as those individuals age 18 and under. included in figure 2 and figure 5. Margin of Error The U.S. Census Bureau publishes a margin of error (potential range for any given estimate) at a 90 percent confidence level. Where estimates are combined to produce new estimates, margin of error results were computed following Chapter 8 of the U.S. Census Bureau’s handbook 8 children and medicaid expansion CCF.GEORGETOWN.EDU February 2021 Endnotes 1 J. Alker and A. Corcoran, “Children’s Uninsured Rate Rises by Largest 9 Meyerson, op. cit. Annual Jump in More than a Decade,” (Washington, DC: Georgetown 10 S.M. Harvey et al., “Medicaid Expansion and Neonatal Outcomes Center for Children and Families, October 2020), available at https://ccf. in Oregon,” Journal of Evaluation in Clinical Practice (December georgetown.edu/2020/10/08/childrens-uninsured-rate-rises-by-largest- 2020): 1– 8, available at https://doi-org.ezproxy.library.wisc. annual-jump-in-more-than-a-decade-2/. edu/10.1111/jep.13524. 2 E. Park, J. Alker, and A. Corcoran, “Jeopardizing a Sound Investment: 11 M. Clark, “Medicaid and CHIP Coverage for Pregnant Women: Why Short-Term Cuts to Medicaid Coverage During Pregnancy and Federal Requirements, State Options,” (Washington, DC: Georgetown Childhood Could Result in Long-Term Harm,” (Washington, DC: The Center for Children and Families, November 2020), available at https:// Commonwealth Fund, December 2020), available at https://www. ccf.georgetown.edu/2020/11/05/medicaid-and-chip-coverage-for- commonwealthfund.org/publications/issue-briefs/2020/dec/short-term- pregnant-women-federal-requirements-state-options/. cuts-medicaid-long-term-harm. 12 J. Daw et al., “Medicaid Expansion Improved Perinatal Insurance 3 A. Searing and D. Ross, “Medicaid Expansion Fills Gaps in Maternal Continuity for Low-Income Women,” Health Affairs 39, no. 9 Health Coverage Leading to Healthier Mothers and Babies,” May (September 2020): 1531- 1539, available at https://doi.org/10.1377/ 2019, available at https://ccf.georgetown.edu/2019/05/09/medicaid- hlthaff.2019.01835. expansion-fills-gaps-in-maternal-health-coverage-leading-to-healthier- 13 E. Johnston et al., “ACA Medicaid Expansion and Insurance Coverage mothers-and-babies/. Among New Mothers Living in Poverty,” Pediatrics 145, no. 5 (May 4 J. Hudson and A. Moriya, “Medicaid Expansion for Adults Had 2020): e20193178, available at https://pediatrics.aappublications.org/ Measurable ‘Welcome Mat’ Effects on Their Children,” Health Affairs 36, content/145/5/e20193178. no. 9 (September 2017), available at https://www.healthaffairs.org/doi/ 14 Gordon, op. cit. full/10.1377/hlthaff.2017.0347. 15 A. Faisal-Cury, et al., “Postpartum Bonding at the Beginning of the 5 J. Meyerson, S. Crawford, and L. Wherry, “Medicaid Expansion Second Year of Child’s life: the Role of Postpartum Depression and Increased Preconception Health Counseling, Folic Acid Intake, and Early Bonding Impairment,” Journal of Psychosomatic Obstetrics & Postpartum Contraception,” Health Affairs 39, no. 11 (November Gynecology, 41, no. 3 (August 2020): 224-230, available at https:// 2020): 1883-1890, available at https://www.healthaffairs.org/doi/ doi.org/10.1080/0167482X.2019.1653846; and D.L. Putnick et al., full/10.1377/hlthaff.2020.00106; S. Roy et al., “The Impact of Medicaid “Trajectories of Maternal Postpartum Depressive Symptoms,” Pediatrics Expansion for Adults Under the Affordable Care Act on Preventive 148, no. 5 (November 2020), available at https://doi.org/10.1542/ Care for Children: Evidence from the Southern United States,” peds.2020-0857. Medical Care 58, no. 11 (November 2020): 945-951, available at https://journals.lww.com/lww-medicalcare/Abstract/2020/11000/ 16 Roy, op. cit. The_Impact_of_Medicaid_Expansion_for_Adults_Under.2.aspx; S. 17 Brown, op. cit. Gordon et al., “Effects of Medicaid Expansion on Postpartum Coverage 18 Ibid. and Outpatient Utilization,” Health Affairs 39, no. 1 (January 2020): 19 R. Yeung, “The Effect of the Medicaid Expansion on Dropout 77-84, available at https://doi.org/10.1377/hlthaff.2019.00547; A. Rates,” Journal of School Health, 90 (August 2020): 745-753, available Dunlop et al., “Postpartum Medicaid Coverage and Contraceptive at https://doi.org/10.1111/josh.12937. Use Before and After Ohio’s Medicaid Expansion Under the Affordable Care Act,” Women’s Health Issues 30, no. 6 (November-December 20 Alker, op. cit. 2020): 426-435, available at https://www.sciencedirect.com/science/ 21 R. Garfield, K. Orgera, and A. Damico, “The Coverage Gap: Uninsured article/abs/pii/S1049386720300785; and E. Brown et al., “Assessment Poor Adults in States that Do Not Expand Medicaid” (Washington, DC: of Rates of Child Maltreatment in States with Medicaid Expansion The Kaiser Family Foundation, January 2020), available at https://www. vs States Without Medicaid Expansion,” JAMA Network Open 2, kff.org/medicaid/issue-brief/the-coverage-gap-uninsured-poor-adults- no. 6 (June 2019): e195529, available at https://doi.org/10.1001/ in-states-that-do-not-expand-medicaid. jamanetworkopen.2019.5529. 22 J. Banthin et al., “Changes in Health Insurance Coverage Due to the 6 Hudson, op. cit. COVID-19 Recession: Preliminary Estimates Using Microsimulation,” 7 J. Haley et al., “Progress in Children’s Coverage Continued to (Washington, DC: The Urban Institute, July 2020), available at https:// Stall out in 2018: Trends in Children’s Uninsurance and Medicaid/ www.urban.org/sites/default/files/publication/102552/changes-in- CHIP Participation,” (Washington, DC: The Urban Institute, October health-insurance-coverage-due-to-the-covid-19-recession_4.pdf. 2020), available at https://www.urban.org/sites/default/files/ 23 Park, op. cit. publication/102983/progress-in-childrens-coverage-continued-stalling- out-in-2018_0.pdf. 8 “Health Coverage for Parents and Caregivers Helps Children,” (Washington, DC: Georgetown Center for Children and Families, 2017), available at https://ccf.georgetown.edu/wp-content/uploads/2017/03/ Covering-Parents-v2.pdf. February 2021 CCF.GEORGETOWN.EDU children and medicaid expansion 9 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 10 children and medicaid expansion CCF.GEORGETOWN.EDU February 2021