Georgetown University
® Health Policy Institute

 

Number of Uninsured Children
Stabilized and Improved Slightly
During the Pandemic

by Joan Alker, Aubrianna Osorio, and Edwin Park

Key Findings

e The number of uninsured children declined
during the COVID-19 pandemic largely due to
federal law which has protected access to health
care for Medicaid beneficiaries by requiring
states to keep them enrolled during the federally
declared COVID-19 public health emergency
in exchange for enhanced federal funding. This
reverses the trend from 2016 to 2019 when the
number of uninsured children had been going up.
Medicaid protections helped ensure coverage
for children whose families lost their employer-
sponsored coverage during the early period of the
pandemic. The continuous coverage protection also
prevented eligible children from losing coverage
due to "procedural reasons," which is a common
occurrence for children under normal operating
procedures in many states. Procedural losses occur
when eligible children fall off the program because
their coverage isn't renewed due to administrative
barriers.

e Twelve states saw significant declines in their
rate and/or number of uninsured children with
Oklahoma, Connecticut, Indiana, Colorado and
Texas seeing the largest improvements. Despite
the improvement, Texas continues to rank last in
the country with the highest rate (11.8 percent) and
number (930,000) of uninsured children.

December 2022

Idaho, Maryland and New York went in the wrong
direction with Idaho seeing the largest jump in the
number of uninsured children-an increase of 46
percent.

Children in low-wage working families with annual
incomes between $30,305 and $54,900 (for a
family of three) saw the biggest reductions in their
uninsured rates.

These coverage gains are at risk when the
Medicaid continuous coverage protection lifts
at the end of the federal COVID-19 public health
emergency. According to a separate analysis
conducted by Georgetown University Center for
Children and Families researchers, an estimated
6.7 million children are at risk of losing coverage
and the child uninsured rate could more than
double if states do not do a good job of keeping
eligible children enrolled when the continuous
coverage protection ends. Most of the children
losing coverage will remain eligible but their
coverage will be dropped due to procedural rather
than eligibility reasons.' As of this writing, the
public health emergency is expected to remain in
place until at least April 11, 2023.

CCF.GEORGETOWN.EDU NUMBER OF UNINSURED CHILDREN DECLINED SLIGHTLY 1
 

Data released by the U.S. Census Bureau's American
Community Survey (ACS) for 2021 finds that nationally

the estimated number and rate of uninsured children went
down slightly from 2019 to 2021. This data provides the
first comprehensive look at what happened to children with
respect to this metric during the first part of the COVID-19
pandemic-as standard ACS data were not available for
2020.

Prior to the pandemic, the number and rate of uninsured
children had been rising for the first time in many years.?
Substantial job losses in the early months of the pandemic
led many to fear that large increases in the rate of uninsured
children and adults would ensue.' Fortunately, this prediction
did not pan out and, in fact as these new data show, the
uninsured rate for children got slightly better. This reversal

of fortune during a difficult period is generally attributed to
federal protections' put in place that ensure that no one

can be disenrolled involuntarily from Medicaid during the
federally-declared COVID-19 public health emergency-in
return for enhanced federal funding to support state Medicaid
programs.® Medicaid enrollment has increased substantially
during the pandemic with child enrollment increasing by 16.1
percent from February 2020 (prior to the continuous coverage
protections being established in March 2020) to June 2022.° 7

Enrollment increases in the Affordable Care Act's Marketplace
due to enhanced subsidies and greater outreach and
enrollment efforts have also played a positive, albeit smaller,
role for children. Overall, increases in public coverage
(primarily Medicaid) more than offset any losses of employer-
sponsored coverage early in the pandemic. Medicaid's
continuous coverage protections also minimized loss of
coverage common in normal times for low- and moderate-
income children due to procedural reasons-also known as
administrative "churn."

Procedural (non-eligibility) losses at renewal occur when
there is insufficient information to verify ongoing eligibility.
Disenrollment for procedural reasons is more prevalent in
states that have not kept pace with others in automating
their renewal systems to efficiently and accurately verify
ongoing eligibility using income and other electronic data
available to the state.' In turn, families in states that have

not modernized have to navigate their way through more
administrative hurdles in order to keep their children enrolled
in Medicaid. This leaves open many potential points of failure

December 2022 CCF.GEORGETOWN.EDU

in the system that could leave more children uninsured.

For example, if families never receive the paper renewal
notice in the mail or find it confusing and are unable to get
through to the call center for assistance, or the state loses
their paperwork, coverage is terminated.®'° Procedural
disenrollments are a bureaucratic failure to streamline the
process and remove unnecessary administrative barriers to
enrollment and retention. In addition, some states have done
a better job than others in working with providers, plans,
and community-based organizations to educate and engage
families in the enrollment and renewal processes.

The number of uninsured children declined from 4.375 million
in 2019 to 4.165 million in 2021 -a five percent decline

of 210,000 (see Figure 1). The rate of uninsured children
nationally declined from 5.7 percent to 5.4 percent (see Figure
2). Both of these changes are statistically significant. This
slight decline followed a period of rising numbers of uninsured
children from 2016 to 2019 when an estimated one million
more children became uninsured." Prior to 2016, the number
of uninsured children had been declining for many years
largely as a consequence of expansions of public coverage
for children through Medicaid and the Children's Health
Insurance Program (CHIP) and steps to make it easier for
eligible children to enroll. Other federal data sources show an
even sharper decline in the child uninsured rate from 2019 to
2021 with approximately 700,000 fewer uninsured children. '?

 
December 2022

 

Figure 1. Number of Uninsured Children in the United States (in millions), 2011-2021

6.2

4.2*

5.9% 5.9
4.9"
4.4*
4.0* 3.9" 4.1"
3.6%
No
Data™

2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021

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 2021, Health Insurance
Historical Tables.

* Change is significant at the 90% confidence level relative to the prior year indicated.

** Due to data quality issues related to the pandemic, the U.S. Census Bureau did not release standard 1-year ACS estimates in 2020.
See methodology section for more information.

Figure 2. Rate of Uninsured Children in the United States, 2011-2021
7.9%

7.5%* 75%

 

2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021

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 2021, Health Insurance
Historical Tables.

* Change is significant at the 30% confidence level relative to the prior year indicated.

* Due to data quality issues related to the pandemic, the U.S. Census Bureau did not release standard 1-year ACS estimates in 2020. See
methodology section for more information.

CCF.GEORGETOWN.EDU NUMBER OF UNINSURED CHILDREN DECLINED SLIGHTLY 3
9

 

What has happened at the state level?

Twelve states saw statistically significant improvements in the | Children in Oklahoma saw the biggest improvement with the

number or rate of uninsured children or (in most cases) both uninsured rate declining from 8.6 percent to 7.4 percent (see
during the examined period; the largest number of children Table 2) although the state still ranks 44th in the country. In
gaining coverage was in Texas with 65,000 more children addition to the continuous coverage protection that was in
insured -although Texas continues to have the largest number _ place in all states, Oklahoma's improvement is likely in part
of uninsured children in the country by far with 930,000 (see a reflection of the "welcome mat" effect of the passage of a
Table 1). Three states saw significant increases in their number _ ballot initiative to implement the ACA's Medicaid expansion
and/or rate of uninsured children (Idaho, Maryland and New for adults-for which enrollment began in Oklahoma in June
York) with Idaho showing the largest increase of 46 percent in of 2021 and the number of enrollees grew quickly."®

their uninsured child population. See Appendix Tables for more

information.

Table 1. Twelve States with Significant Decrease in Number of Uninsured Children, 2019-2021

 

2019 Number 2021 Number 2019-2021 Change in

Uninsured Uninsured Number of Uninsured
United States 4,375,000 4,165,000 -210,000
Arizona 161,000 146,000 -15,000
Colorado 73,000 61,000 -12,000
Connecticut 27,000 19,000 -8,000
Georgia 197,000 176,000 -21,000
Illinois 120,000 95,000 -25,000
Indiana 119,000 100,000 -19,000
Maine 15,000 11,000 -4,000
Michigan 78,000 69,000 -9,000
New Jersey 88,000 76,000 -12,000
Oklahoma 86,000 75,000 -11,000
Oregon 38,000 31,000 -7,000
Texas 995,000 930,000 -65,000

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 2021, Health Insurance Historical Tables.

Table 2. Nine States with Significant Decrease in Rate of Uninsured Children, 2019-2021

 

2019 2021 2019-2021 Percentage
Uninsured Rate Uninsured Rate Point Change
United States 5.7 5.4 -0.3
Colorado 5.5 4.6 -0.9
Connecticut 3.5 2.4 -1.1
Georgia 7.4 6.6 -0.8
Illinois 4.0 3.2 -0.8
Indiana 7.1 6.0 -1.1
Michigan 3.4 3.0 -0.4
New Jersey 4.3 3.6 -0.7
Oklahoma 8.6 7.4 -1.2
Texas 12.7 11.8 -0.9

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 2021, Health Insurance Historical Tables.

December 2022 CCF.GEORGETOWN.EDU NUMBER OF UNINSURED CHILDREN DECLINED SLIGHTLY 4
©

 

States in New England continue to have the lowest uninsured
rates for children. The South is a mixed picture with Texas
having the highest rate and number of uninsured children

in the country, and Florida and Georgia continuing to have

a large percentage of the uninsured children overall and
relatively high rates in general. As a region, the Mountain West
is falling most consistently behind the national average (with
the exception of Colorado). See Figure 3.

Figure 3. States with Higher and Lower Rates of Uninsured Children
than the National Rate, 2021

   
     
   

Texas has
the highest
uninsured rate

Massachusetts
has the lowest
uninsured rate

Higher than national rate
(14 states)

Lower than national rate
(27 states)

No statistically significant
difference (10 states
including D.C.)

  

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 2021, Health Insurance Historical Tables.

Which Children Were More Likely to Gain Coverage?

The uninsured rate for children overall has declined since
2019, but some groups of children have seen bigger coverage
gains. American Indian and Alaska Native children saw the
largest decline in the uninsured rate of any racial group, falling
by two percentage points between 2019 and 2021 (see Figure
4). White children and Asian, Native Hawaiian, and Pacific
Islander children also saw statistically significant declines in
uninsurance, but the uninsured rate for children of another
race or multiple races increased in 2021."

December 2022

Looking at ethnicity, uninsured rates for both Hispanic/Latino
and non-Hispanic/Latino children fell (see Figure 4). The
disparity between Hispanic and non-Hispanic children also
narrowed somewhat in 2021, although the uninsured rate for
Hispanic children is still more than twice as high as it is for
non-Hispanic children.

CCF.GEORGETOWN.EDU NUMBER OF UNINSURED CHILDREN DECLINED SLIGHTLY 5
9

 

Figure 4, Rate of Uninsured Children in the United States by Race and Ethnicity, 2019-2021

13.8%
2019
wl 2021 11.8%*
9.2%
8.6%*
7.6%*
6.9%
5.6%
44% 44%* 4.6% 4.7% 45% *
9 3.8%* o a 4.2%
Asian/ White Black/African Other/ American Not Hispanic/ Hispanic/

Native Hawaiian/ American Multiracial Indian/Alaska Latino Latino
Pacific Islander Native

Source: Georgetown University Center for Children and Families analysis of the U.S. Census 2019-2021 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.

Children in low-wage working families were more likely to gain
coverage. Children in families earning between 138 percent
and under 250 percent of the Census poverty threshold
($30,305 to under $54,900 for a family of 3) saw the largest
gains, and children at the lowest end of the income scale also
saw a significant improvement in their health coverage rates
(see Table 3).

The uninsured rates for children across all ages fell. For
young children under age 6 the uninsured rate declined
from 4.7 percent in 2019 to 4.5 percent in 2021, and the rate
for school-age children fell from 6.1 percent in 2019 to 5.7
percent in 2021.

Table 3. Rate of Uninsured Children in the United States by Poverty Threshold, 2019-2021

December 2022

Poverty Threshold** 2019 2021
0-137% of poverty 7.7% 7.A%*
138-250% of poverty 7.7% 7.0%"
250% of poverty or above 3.8% 3.7%

Source: Georgetown University Center for Children and Families analysis of the U.S. Census 2019-2021 American Community
Survey (ACS), Table B27010.

* Change is significant at the 99% confidence level relative to the prior year indicated.

** Census poverty thresholds differ from the Department of Health and Human Services' (HHS) Federal Poverty Levels (FPL). See
methodology section for more information.

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Conclusion

The improvement of the child uninsured rate has been a

bright spot for children during the dark days of the pandemic.

However, troubled waters likely lie anead. Medicaid's
continuous coverage protection will expire when the federal
COVID-19 public health emergency ends, putting millions
of children at risk of losing Medicaid. Separately, we have
estimated that 6.7 million children are at risk for a period of
uninsurance."* Of the children projected to lose Medicaid
after the continuous coverage protection is removed, an
estimated 3 out of 4 will still be eligible.'* Unfortunately, there
are numerous potential points of failure in the system that
put children and their families at risk of falling through the
cracks as states take up the unprecedented challenge of
redetermining eligibility for over 80 million people currently
covered by Medicaid.""

Eligible children in states with less advanced systems and
more red tape and administrative barriers to enrollment

will be at greater risk of inappropriately losing Medicaid
while children in states with 12-month or longer periods of
continuous eligibility and other strategies in place will be
better protected from becoming uninsured. While there is a

longstanding option for states to provide up to 12 months of
continuous eligibility for children in their Medicaid and CHIP
programs, as of January 2022, only 24 states did so for all
children in Medicaid and CHIP."* Seventeen states and the
District of Columbia do not have continuous eligibility for
Medicaid or CHIP for any children. Congress should consider
guaranteeing 12 months of continuous eligibility for children in
Medicaid and CHIP regardless of where they live.'® States can
also pursue longer periods of Medicaid eligibility for young
children through Section 1115 authority as was recently
approved for Oregon and is in process in Washington, New
Mexico and California." These policies will help reduce but
not eliminate the perpetual problem of administrative churn
that leaves children with gaps in health coverage.

Children continue to face increased threats to their health
from COVID-19, RSV and other viruses while families continue
to struggle to make ends meet. The Medicaid continuous
coverage provision provided stability during a tumultuous time
and policymakers should proceed with caution when they
remove that important protection.

 

December 2022

CCF.GEORGETOWN.EDU NUMBER OF UNINSURED CHILDREN DECLINED SLIGHTLY 7
9

 

Methodology

Data Sources

This report from the Georgetown University Center for Children
and Families (CCF) uses data from the U.S. Census Bureau
American Community Survey (ACS). CCF analyzes two ACS
data products: 1) Health Insurance Historical Table HIC-5.
Health Insurance Coverage Status and Type of Coverage

by State - Children Under 19: 2008 to 2021, and 2) the

2021 1-Year ACS Estimates Detailed Tables published by

the Census Bureau on data.census.gov. Please note that,
because of differences in sample size and data processing,
the estimates published in this report may differ from other
estimates produced using either the 5-year ACS estimates

or ACS microdata (including the Census Bureau's Public Use
Microdata Sample (PUMS) or the University of Minnesota's
Integrated Public Use Microdata Series (IPUMS)), despite the
fact that all of these datasets are based on the same American
Community Survey.

Because of data quality issues related to the pandemic, the
Census Bureau did not publish standard 1-year estimates for
2020 but instead only released a set of 1-year experimental
estimates. The experimental estimates are not available
through data.census.gov and the Census Bureau notes that
these experimental estimates should not be compared to other
ACS 1-year estimates, so CCF excludes 2020 ACS data from
all of its analyses.

Margin of Error, Data Reliability and
Suppression, and Statistical Significance

The Census Bureau provides a margin of error at a 90 percent
confidence level for each estimate it publishes. When CCF
calculates a new estimate (such as when we combine racial/
ethnic groups or calculate percentages/rates), we also calculate
its margin of error, using formulas provided by the Census
Bureau in their handbook: "Understanding and Using American
Community Survey Data: What All Data Users Need to Know"
(September 2020). CCF does not take the margin of error

into account when ranking states by the number and percent
of uninsured children by state. Although we do not publish
margins of error in this report, they are available upon request.

CCF calculates coefficients of variation (also known as relative
standard errors) to measure data reliability for each estimate.
CCF suppresses any estimate with a CV larger than 25
percent.

December 2022

CCF uses the Census Bureau's Statistical Testing Tool to
determine statistical significance between estimates at a
90 percent confidence level. Differences between estimates
should not be assumed to be statistically significant unless
specifically discussed or marked as such.

Geographic Levels

The Census Bureau publishes 1-year ACS estimates for all
geographic areas with a population of 65,000 or more, which
includes all regions, states (including the District of Columbia),
and some counties. Please note that 1-year estimates will
differ from 5-year estimates, which CCF may use elsewhere
for analyses of smaller geographic levels like counties or
school districts. CCF uses Census Bureau designations to
report and characterize regional data.

Poverty Status

Data on poverty thresholds only include individuals for whom
the Gensus Bureau could determine poverty status for the
past year. This population is slightly smaller than the total
non-institutionalized population of the U.S. (the universe for all
other data used in this report). The Census Bureau determines
an individual's poverty status by comparing that person's
income in the past 12 months to Census Poverty Thresholds
(CPTs). Notably, Census Poverty Thresholds differ from the
poverty guidelines (commonly known as the Federal Poverty
Level or FPL) determined by the Department of Health and
Human Services (HHS), and may differ considerably for the
separate FPLs that HHS determines for Alaska and Hawaii.

Health Insurance Coverage and
Medicaid Undercount

ACS data represents a "point-in-time" estimate of an
individual's insurance coverage, meaning that the survey
collects information on the respondent's coverage only at
the moment they complete the form, not at another point
during the year. The ACS considers individuals who reported
no health insurance coverage through any of the response
options (employer-based health insurance, direct purchase
health insurance, Medicare coverage, Medicaid/means-
tested public coverage, TRICARE/military health coverage,
VA health coverage, Indian Health Service (IHS), or another
type of comprehensive health coverage) to be uninsured.

CCF.GEORGETOWN.EDU NUMBER OF UNINSURED CHILDREN DECLINED SLIGHTLY 8
©

 

The Census Bureau does not consider access to Indian
Health Service (IHS) alone as a comprehensive form of health
insurance coverage. Consequently, individuals who indicate
that IHS is their only source of coverage are also designated
as uninsured.

ACS estimates are not adjusted by the Census Bureau

(or by CCF) to address the "Medicaid undercount" often
observed when comparing surveys to the reported numbers
of individuals enrolled in Medicaid and CHIP using federal
and state administrative data. For example, ACS data show
that 30.5 million children had Medicaid coverage ither alone
or in combination with another type of coverage) in 2021,
while administrative data show average enrollment over the
same period equal to 40.3 million, a difference of nearly 10
million children. Additionally, recent research on the decennial
Census shows that young children are consistently and
significantly undercounted, likely worsening the Medicaid
undercount among children. In 2021, the Medicaid continuous
coverage provision may affect children's reported coverage
source- including uninsurance-if families are unaware that
they still have Medicaid coverage.

Demographic Characteristics

"Children," as noted above, are defined as individuals under
age 19 (ages 0-18).

The American Community Survey allows respondents to self-
identify as the following races: White alone, Black/African-
American alone, American Indian/Alaska Native alone, Asian
alone, Native Hawaiian/Pacific Islander alone, "Some other
race" alone, and "Two or more races." To improve sample
sizes and data reliability, CCF combines estimates for Asian
alone and Native Hawaiian or Other Pacific Islander alone and

reports the calculations as "Asian, Native Hawaiian, or Other
Pacific Islander" and combines "Some other race" alone and
"Two or more races" and reports the calculations as "Other
or Multiracial." Except for "Other or Multiracial," all racial
categories refer to individuals who reported belonging only to
one race.

The Census Bureau recognizes and reports race and Hispanic
origin (i.e., ethnicity) as separate and distinct concepts and
variables. "Hispanic or Latino" refers to individuals who self-
identified as being Hispanic or Latino, while "non-Hispanic/
Latino" refers to individuals who indicated that they were not
of Hispanic or Latino origin. CCF calculates estimates for
non-Hispanic or Latino populations by subtracting estimates
for Hispanic or Latino individuals from the total population
estimate for children. As "Hispanic or Latino" refers to a
person's ethnicity, Hispanic and non-Hispanic individuals may
be of any race.

In 2020, the Census Bureau made changes to the race and
ethnicity questions on the ACS which may affect health
coverage comparisons related to race and ethnicity between
the 2021 and 2019 1-year estimates. These changes may
affect the "Some Other Race" or multiple race categories in
particular, whose numbers more than doubled between 2019
and 2021. This increase, which may be related to changes in
question design, may also affect the distribution of children
across other racial groups. As a result, the Census Bureau
recommends caution in comparing 2021 and 2019 ACS
estimates related to race/ethnicity.

A more detailed account of CCF's methodology for this report
is available online.

The authors would like to thank Tricia Brooks, Cathy Hope, and Hannah Klukoff for their
thoughtful review. 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 at the McCourt School of Public Policy.

December 2022

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)

Appendix Table 1. Number of Uninsured Children by State, 2019-2021

 

     

2019 Number 2019 State 2021 Number 2021 State

      

State

Uninsured Ranking Uninsured Ranking

United States 4,375,000 - 4,165,000 -

Alabama 40,000 21 47,000 27
Alaska 18,000 12 15,000 10
Arizona 161,000 47 146,000 47
Arkansas 43,000 23 43,000 22
California 334,000 49 321,000 49
Colorado 73,000 33 61,000 30
Connecticut 27,000 17 19,000 15
Delaware 10,000 5) 8,000 4
District of Columbia 3,000 1 5,000 2
Florida 343,000 50 332,000 50
Georgia 197,000 48 176,000 48
Hawaii 9,000 4 9,000 Ey
Idaho 24,000 16 35,000 20
Illinois 120,000 43 95,000 4
Indiana 119,000 42 100,000 42
lowa 22,000 14 26,000 17
Kansas 43,000 23 38,000 21
Kentucky 45,000 25 43,000 22
Louisiana 50,000 28 45,000 25
Maine 15,000 8 11,000 6
Maryland 48,000 27 62,000 31
Massachusetts 22,000 14 18,000 13
Michigan 78,000 34 69,000 34
Minnesota 42,000 22 44,000 24
Mississippi 46,000 26 46,000 26
Missouri 95,000 39 86000 39
Montana 15,000 8 17000 12
Nebraska 28,000 18 24000 16
Nevada 58,000 31 63,000 32
New Hampshire 10,000 5 11,000 6
New Jersey 88,000 38 76,000 36
New Mexico 29,000 19 32,000 19
New York 101,000 41 115,000 43
North Carolina 142,000 46 135,000 45
North Dakota 15,000 8 14,000 9
Ohio 131,000 45 140,000 46
Oklahoma 86,000 37 75,000 35
Oregon 38,000 20 31,000 18
Pennsylvania 128,000 44 126,000 44
Rhode Island 4,000 3 6,000 3
South Carolina 69,000 32 63,000 32
South Dakota 18,000 12 18,000 13
Tennessee 80,000 35 80,000 38
Texas 995,000 51 930,000 51
Utah 82,000 36 79,000 37
Vermont 3,000 1 2,000 1
Virginia 97,000 40 88,000 40
Washington 54,000 30 55,000 29
West Virginia 13,000 7 13,000 8
Wisconsin 51,000 29 54,000 28
Wyoming 15,000 8 16,000 11

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 2021, Health Insurance Historical Tables.

December 2022 CCF.GEORGETOWN.EDU NUMBER OF UNINSURED CHILDREN DECLINED SLIGHTLY 10
 

Appendix Table 2. Rate of Uninsured Children by State, 2019-2021

 

2019 Uninsured 2019 State 2021 Uninsured 2021 State
Rate Ranking Rate Ranking
United States 5.7 - 5.4 -
Alabama 3.5 12 4 18
Alaska 9.4 49 7.9 46
Arizona 9.2 48 8.5 48
Arkansas 5.9 36 5.8 34
California 3.6 15 3.5 14
Colorado nO 29 4.6 27
Connecticut 3.5 12 2.4 3
Delaware 4.8 24 3.7 16
District of Columbia 2 3 3.7 16
Florida 7.6 42 7.3 42
Georgia TA 4 6.6 39
Hawaii 2.8 6 2.8 6
Idaho 5 27 7 40
Illinois 4 18 3.2 9
Indiana 7.1 40 6 36
lowa 2.9 7 3.4 12
Kansas 5.8 33 5 30
Kentucky 4.3 20 4 18
Louisiana 4.4 22 4 18
Maine 5.6 30 4.3 23
Maryland 3.4 10 4.3 23
Massachusetts 1.5 1 1.3 1
Michigan 3.4 10 3 7
Minnesota 3.1 8 3.2 9
Mississippi 6.1 37 6.2 37
Missouri 6.5 39 5.9 35
Montana 6.2 38 7 40
Nebraska 5.7 31 47 28
Nevada 8 45 8.6 49
New Hampshire 3.7 16 4 18
New Jersey 4.3 20 3.6 15
New Mexico 5.7 31 6.4 38
New York 2.4 5 2.6 5
North Carolina 5.8 33 ono 33
North Dakota 7.8 43 7.3 42
Ohio 4.8 24 5.1 31
Oklahoma 8.6 47 7.4 44
Oregon 41 19 3.4 12
Pennsylvania 46 23 4.4 25
Rhode Island 1.9 2 2.5 4
South Carolina 5.8 33 5.3 32
South Dakota 7.8 43 7.6 45
Tennessee 5 27 4.9 29
Texas 12.7 51 11.8 51
Utah 8.3 46 7.9 46
Vermont 2.1 4 1.9 2
Virginia 49 26 44 25
Washington 3.1 8 3.1 8
West Virginia 3.5 12 3.3 11
Wisconsin 3.8 17 4 18
Wyoming 10.6 50 11.4 | 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 2021, Health Insurance Historical Tables.

December 2022 CCF.GEORGETOWN.EDU NUMBER OF UNINSURED CHILDREN DECLINED SLIGHTLY 11
)

 

Appendix Table 3. Change in the Number of Uninsured Children by State, 2019 and 2021

 

2019 Number 2021 Number 2019-2021 Change in 2019-2021
Uninsured Uninsured Number of Uninsured Percent Change
United States 4,375,000 4,165,000 -210,000* -4.8%
Alabama 40,000 47,000 7,000 17.5%
Alaska 18,000 15,000 -3,000 -16.7%
Arizona 161,000 146,000 -15,000* -9.3%
Arkansas 43,000 43,000 0 0.0%
California 334,000 321,000 -13,000 -3.9%
Colorado 73,000 61,000 -12,000* -16.4%
Connecticut 27,000 19,000 -8,000* -29.6%
Delaware 10,000 8,000 -2,000 -20.0%
District of Columbia 3,000 5,000 2,000 66.7%
Florida 343,000 332,000 -11,000 -3.2%
Georgia 197,000 176,000 -21,000* -10.7%
Hawaii 9,000 9,000 0 0.0%
Idaho 24,000 35,000 11,000" 45.8%
Illinois 120,000 95,000 -25,000* -20.8%
Indiana 119,000 100,000 -19,000* -16.0%
lowa 22,000 26,000 4,000 18.2%
Kansas 43,000 38,000 -5,000 -11.6%
Kentucky 45,000 43,000 -2,000 -4.4%
Louisiana 50,000 45,000 -5,000 -10.0%
Maine 15,000 11,000 -4,000* -26.7%
Maryland 48,000 62,000 14,000* 29.2%
Massachusetts 22,000 18,000 -4,000 -18.2%
Michigan 78,000 69,000 -9,000* -11.5%
Minnesota 42,000 44,000 2,000 4.8%
Mississippi 46,000 46,000 0 0.0%
Missouri 95,000 86,000 -9,000 -9.5%
Montana 15,000 17,000 2,000 13.3%
Nebraska 28,000 240,00 -4,000 -14.3%
Nevada 58,000 63,000 5,000 8.6%
New Hampshire 10,000 11,000 1,000 10.0%
New Jersey 88,000 76,000 -12,000* -13.6%
New Mexico 29,000 32,000 3,000 10.3%
New York 101,000 115,000 14,000* 13.9%
North Carolina 142,000 135,000 -7,000 -4.9%
North Dakota 15,000 14,000 -1,000 -6.7%
Ohio 131,000 140,000 9,000 6.9%
Oklahoma 86,000 75,000 -11,000* -12.8%
Oregon 38,000 31,000 -7,000* -18.4%
Pennsylvania 128,000 126,000 -2,000 -1.6%
Rhode Island 4,000 6,000 2,000 50.0%
South Carolina 69,000 63,000 -6,000 -8.7%
South Dakota 18,000 18,000 0 0.0%
Tennessee 80,000 80,000 0 0.0%
Texas 995,000 930,000 -65,000* -6.5%
Utah 82,000 79,000 -3,000 -3.7%
Vermont 3,000 2,000 -1,000 -33.3%
Virginia 97,000 88,000 -9,000 -9.3%
Washington 54,000 55,000 1,000 1.9%
West Virginia 13,000 13,000 0 0.0%
Wisconsin 51,000 54,000 3,000 5.9%
Wyoming 15,000 16,000 1,000 6.7%

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 2021, Health Insurance Historical Tables.

* Change is significant at the 90% confidence level relative to the prior year indicated.

December 2022 CCF.GEORGETOWN.EDU NUMBER OF UNINSURED CHILDREN DECLINED SLIGHTLY 12
 

Appendix Table 4. Change in the Rate of Uninsured Children by State, 2019-2021

 
  

2019 2021 2019-2021 Percentage

  

State

   

Uninsured Rate Uninsured Rate Point Change

United States 5.7 5.4 -0.3*
Alabama 3.5 4.0 0.5
Alaska 9.4 7.9 -1.5
Arizona 9.2 8.5 -0.7
Arkansas 5.9 5.8 -0.1

California 3.6 3.5 -0.1

Colorado So 4.6 -0.9*
Connecticut 3.5 2.4 -1.1*
Delaware 4.8 3.7 -1.1

District of Columbia 2.0 3.7 1.7
Florida 7.6 7.3 -0.3
Georgia 7.4 6.6 -0.8*
Hawaii 2.8 2.8 0
Idaho 5.0 7.0 2.0%
Illinois 4.0 3.2 -0.8*
Indiana 7.1 6.0 -1,1*
lowa 2.9 3.4 0.5
Kansas 5.8 5.0 -0.8
Kentucky 4.3 4.0 -0.3
Louisiana 4.4 4.0 -0.4
Maine 5.6 4.3 -1.3
Maryland 3.4 4.3 0.9*
Massachusetts 1.5 1.3 -0.2

Michigan 3.4 3.0 -0.4*
Minnesota 3.1 3.2 0.1

Mississippi 6.1 6.2 0.1

Missouri 6.5 5.9 -0.6
Montana 6.2 7.0 0.8
Nebraska 5.7 4.7 -1.0
Nevada 8.0 8.6 0.6
New Hampshire 3.7 4.0 0.3
New Jersey 4.3 3.6 -0.7*
New Mexico 5.7 6.4 0.7
New York 2.4 2.6 0.2
North Carolina 5.8 5.5 -0.3
North Dakota 78 7.3 -0.5
Ohio 4.8 5.1 0.3
Oklahoma 8.6 74 -1,2*
Oregon 4.1 3.4 -0.7
Pennsylvania 4.6 4.4 -0.2
Rhode Island 1.9 2.5 0.6
South Carolina 5.8 5.3 -0.5
South Dakota 7.8 7.6 -0.2

Tennessee 5.0 4.9 -0.1

Texas 12.7 11.8 -0.9*
Utah 8.3 7.9 -0.4
Vermont 2.1 1.9 -0.2

Virginia 49 44 -0.5
Washington 3.1 3.1 0
West Virginia 3.5 3.3 -0.2
Wisconsin 3.8 4.0 0.2

Wyoming 10.6 11.4 0.8

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 2021, Health Insurance Historical Tables.

* Change is significant at the 90% confidence level relative to the prior year indicated.

December 2022 CCF.GEORGETOWN.EDU NUMBER OF UNINSURED CHILDREN DECLINED SLIGHTLY 13
9

 

Endnotes

1 Office of the Assistant Secretary for Planning and Evaluation,
"Unwinding the Medicaid Continuous Enrollment Provision: Projected
Enrollment Effects and Policy Approaches" (Office of the Assistant
Secretary for Planning and Evaluation, » August 2022), available at https://

 

provision.

? Alker, J. and Corcoran, A., "Children's Uninsured Rate Rises by Largest
Annual Jump in More Than A Decade" (Georgetown University Center for
Children and Families, October 2020) available at https://ccf,georgetown,
edu/wp-content/uploads/2020/10/ACS-Uninsured-Kids-2020 10-06-
edit-3.pdf.

3 Alker, J., "How much will COVID-19 drive up uninsured numbers? New

report underscores how hard it is to know" (Georgetown University Center
for Children and Families, July 2020) available at https: //ect.georgetown.

 

new-report-underscores-how-hard-it-is-to-know/.

* For an explainer of the federal law, see Brooks, T. and Schneider, A.,
"The Families First Coronavirus Relief Act: Medicaid and CHIP Provisions
Explained" (Georgetown University Center for Children and Families,
March 2020) available at https://ccf.qgeorgetown,edu/wp-conten

uploads/2020/03/Families-First-Final-3.30-V2.pdf.

5 See Slide 3 of "July 2022 Medicaid and CHIP Enrollment Trends
Snapshot" (Centers for Medicare and Medicaid Services) available at

 

information/downloads/i uly-2022-medicaid-chip-enrollment-trend-
snapshot.pdf. See also Corallo, B. and Moreno, S. "Analysis of Recent
National Trends in Medicaid and CHIP Enrollment" (Kaiser Family
Foundation, October 2022) available at https://Awww.kff.org/coronavirus-
covid-19/issue-brief/analysis-of-recent-national-trends-in-medicaid-and-
chip-enrollment/.

® Georgetown University Center for Children and Families analysis of
February 2020-June 2022 Centers for Medicare and Medicaid Services
State Medicaid and CHIP Applications, Eligibility Determinations,

and Enrollment Data, available at https://data.medicaid.gov/
dataset/6165f45b-ca93-5bb5-9d06-db29c692a360.

7 As in many national surveys, Medicaid coverage as reported in ACS
data is often lower compared to the actual numbers of Medicaid enrollees
reflected in administrative data sources. This is known as the "Medicaid
undercount." See, for example, Michel Boudreaux et al., "Medicaid
expansion and the Medicaid undercount in the American Community
Survey," Health Services Research 54, no. 6 (December 2019): 1263-
1272. Please see methods section for more information.

8 Medicaid and CHIP Payment and Access Commission (MACPAC), "An
Updated Look at Rates of Churn and Continuous Coverage in Medicaid
and CHIP" (MACPAC, October 2021) available at https:/Avww.macpac.
ov/wp-content/uploads/2021/10/An-Updated-Look-at-Rates-of-Churn-
and-Continuous-Coverage-in-Medicaid-and-CHIP. pdf.

° Office of the Assistant Secretary for Planning and Evaluation (ASPE),
"Medicaid Churning and Continuity of Care: Evidence and Policy
Considerations Before and After the COVID-19 Pandemic" (ASPE, April
2021), available at httos://aspe,hhs,gov/sites/default/files/migrated
legacy files//199881/medicaid-churning-ib.pdf.

 Wikle, S., "States Must Plan Now to Limit Medicaid Churn When
Continuous Coverage Ends" (The Center for Law and Social Policy
(CLASP), July 2022) available at https://www.clasp,org/wp-content/
uploads/2022/07/2022.07.28 States-Must-Plan-Now-to-Limit-Medicaid-
Churn-When-Continuous-Coverage-Ends.pdf.

December 2022

1 Alker, J. and Corcoran, A., "Children's Uninsured Rate Rises by Largest
Annual Jump in More Than A Decade" (Georgetown University Center for
Children and Families, October 2020) available at https://ccf.georgetown.
edu/wp-content/uploads/2020/10/ACS-Uninsured-Kids-2020_10-06-
it-3.pdf.

12 Jennifer M. Haley et al., "Children's Uninsurance Fell Between 2019

to 2021, but Progress Could Stall Wnen Pandemic Protections Expire"
(Urban Institute, June 2022) available at httos:/Avww.urban.org/research/

publication/childrens-uninsurance-fell-between-2019-and-2021-progress-
could-stall-when.

13 Searing, A., "A Tale of Two Medicaid Expansions: Missouri v.
Oklahoma" (Georgetown University Center for Children and Families,
November 2021) available at https://ccf.georgetown.edu/2021/11/30/a-
tale-of-two-medicaid-expansions-missouri-v-oklahoma/.

'4 The Census Bureau made changes to the ACS race and ethnicity
questions beginning in 2020, which may affect the changes observed
between 2019 and 2021. There are now many more children in this
category which may confound these results. Please see methodology
section for more information.

18 Alker, J. and Brooks, T., "Millions of Children May Lose Medicaid:
What Can Be Done to Help Prevent Them from Becoming Uninsured?"
(Georgetown University Center for Children and Families: February 2022),
available at https://ccf.georgetown.edu/2022/02/17/millions-of-children-
may-lose-medicaid-what-can-be-done-to-help-prevent-them-from-
becoming-uninsured/.

18 ASPE 2022, op. cit.
17 CGF analysis of CMS enrollment data, op. cit.

18 Some additional states provide continuous eligibility for only some
children. For example, Florida offers 12 months continuous eligibility
only for children under age 6, with older children receiving only 6 months
of eligibility. Other states like Texas provide continuous eligibility only

for children in separate state CHIP programs. See Tricia Brooks et al.,
"Medicaid and CHIP Eligibility and Enrollment Policies as of January
2022: Findings from a 50-State Survey" (Georgetown University Center
for Children and Families and Kaiser Family Foundation, March 2022)
available at https://www.kff.org/medicaid/report/medicaid-and-chip-

eligibility-and-enrollment-policies-as-of-january-2022-findings-from-a-50-
state-survey/.

18 Georgetown University Center for Children and Families, "Medicaid
and CHIP Continuous Coverage for Children" (Georgetown University
Center for Children and Families, October 2022) available at https://ccf.
georgetown.edu/2022/10/07/medicaid-and-chip-continuous-coverage-
for-children/.

0 See Alker, J. and Burak, E., "Oregon Leads the Nation in Covering
Children from Birth to Kindergarten: What State Will be Next"
(Georgetown University Center for Children and Families, September
2022) available at https://ccf.georgetown.edu/2022/09/28/oregon-leads-
the-nation-by-covering-children-in-medicaid-from-birth-to-kindergarten-
which-state-will-be-next/.

 

CCF.GEORGETOWN.EDU NUMBER OF UNINSURED CHILDREN DECLINED SLIGHTLY 14