Report Finds Disparities in Children’s Health Insurance Coverage

Around 3.6 million children in the US are uninsured, but coverage varies by race, state, and income, highlighting stark disparities in children’s health insurance coverage, according to a report from the State Health Access Data Assistance Center (SHADAC), funded by the Robert Wood Johnson Foundation.

Researchers assessed uninsurance rates among children in all 50 states and Washington, DC between 2016 and 2020 using estimates from the US Census Bureau’s American Community Survey (ACS).

Nationally, 5 percent of children aged 17 and younger did not have health insurance, which equaled about 3.6 million kids. However, coverage levels varied when researchers looked at individual states.

For example, Massachusetts and Vermont had the lowest uninsurance rate for children at 1.3 percent. Washington DC and Rhode Island trailed at 1.9 percent and 2.2 percent, respectively. The rate in New York, West Virginia, and Iowa was 2.5 percent.

Meanwhile, Texas had the highest uninsurance rate at 10.6 percent, leaving 785,500 children without insurance. The children’s uninsurance rates in Wyoming (9.3 percent), Alaska (8.4 percent), Arizona (8.2 percent), Oklahoma (7.9 percent), and North Dakota (7.9 percent) were also higher than the national average.

Although Medicaid expansion under the Affordable Care Act (ACA) does not directly impact children, states that expanded Medicaid saw greater improvements in children’s health insurance rates. This may be due to improved awareness of coverage eligibility or parents enrolling their children in coverage at the same time they enrolled themselves.

This correlation was reflected in the report, as six of the ten states with the highest uninsurance rates for children had not expanded Medicaid as of 2016. On the other hand, all ten states with the lowest uninsurance rates had implemented Medicaid expansion.

Children’s health insurance rates also differed by race and ethnicity, researchers found.

American Indian and Alaska Native children had the highest uninsurance rate across all racial and ethnic groups at 14.1 percent, nearly three times as high as the national average. The uninsurance rate was 7.8 percent for Latino children and 6 percent for Native Hawaiian and other Pacific Islander children.

Uninsurance rates were lower among Black children (4.2 percent) and White children (3.9 percent). Asian children and kids of multiple races had the lowest uninsurance rate of 3.6 percent.

Researchers looked at income levels and found that uninsurance was higher among lower-income children.

Children from households with incomes between 0 and 138 percent of the federal poverty (FPL) level had an insurance rate of 6.5 percent. These lower-income children are likely eligible for Medicaid or CHIP coverage and may not be enrolled, indicating the need for better outreach and enrollment efforts.

Children from households with incomes of 401 percent of FPL or higher had an insurance rate of 2.2 percent. Children from families with incomes between 139 and 400 percent of FPL, classified as moderate incomes, had an insurance rate of 5.8 percent.

Immigration status and citizenship can also significantly impact access to health insurance coverage for adults and children alike. Only American citizens and certain lawfully present residents are eligible for Medicaid and CHIP coverage. Some legal permanent residents must wait five years before enrolling in Medicaid, while undocumented immigrants are not eligible for federal coverage at all.

Some states have established programs that fund comprehensive or limited health insurance coverage for undocumented children. Nevertheless, there are still disparities between American citizens and non-citizens.

The uninsurance rate for children who were American citizens was 4.5 percent. In contrast, 15.8 percent of non-citizen children were uninsured, equaling almost 520,000 kids.

Age was another contributing factor to insurance status, with older children between 12 and 17 (5.8 percent) more likely to be uninsured than children five and younger (4.3 percent).

Additionally, children living in non-metropolitan areas (6.2 percent) had a higher insurance rate compared to those living in metropolitan areas (4.7 percent).

Medicaid and CHIP have played a key role in providing children with health insurance coverage, especially during the COVID-19 pandemic. The public health emergency (PHE) was accompanied by policies that required continuous coverage and paused eligibility verifications.

However, the children’s uninsurance rate may escalate when the PHE and Medicaid-related policies expire, according to research from Urban Institute.