The State of America's Children® 2020

After three years of chemotherapy, five-year-old Abel Sewell of Chattanooga, TN was finally leukemia-free.¹ But Abel still needed monthly blood tests to make sure the cancer wasn’t coming back. At his first post-cancer visit to the doctor, Abel and his mother Tricia were told he was no longer covered by health insurance. Abel had been disenrolled from Tennessee’s Medicaid program, TennCare, which had previously paid for all of his cancer treatments. Tricia was faced with a choice no parent should ever have to make—forgo the necessary cancer screenings or pay for them out of pocket. She chose to pay and did so for at least eight months. Then Abel’s older brother Jacob, who has ADHD, also lost his TennCare coverage. Eventually, the Sewell brothers’ medical bills added up to as much as $900 a month, forcing the family to extend its mortgage and add decades of debt to a modest home that was nearly paid off. The family was even forced to skip a few of Abel’s blood tests, putting his health at risk. “It has felt horrible,” Tricia told The Tennessean. “But when these bills come in, it makes you feel even worse.” Shamefully, Abel and Jacob are just two of the 425,000 children who lost their health insurance last year.²

To survive and thrive, all children need access to comprehensive, affordable health coverage that is easy to get and to keep. Children with health coverage are more likely to receive the preventive services they need, including immunizations; miss fewer days of school and have better educational outcomes and grow up to be economically secure and contribute to their communities.³

After decades of hard-fought progress to expand access to comprehensive, affordable health coverage for children through expansions of Medicaid, the Children’s Health Insurance Program (CHIP) and the Affordable Care Act (ACA), our nation had brought the rate of uninsured children to a record low. But what happened to Abel and his brother Jacob is one example of how children’s health coverage is sliding perilously backwards: 2017 and 2018 marked the first increases in the number of uninsured children in the U.S. in a decade.

• In 2018, 1 in 18 children under age 19 were uninsured—nearly 4.3 million. School-aged children (ages 6-17) represented more than 3 million of the nearly 4.3 million uninsured children in 2018 (see Table 13).
• The number of uninsured children in the United States increased by 425,000 between 2017 and 2018.⁴
• This dramatic loss of coverage was most pronounced for white and Latino children (some of whom may fall into both categories), young children under 6 and children in low- and moderate- income families who earn between 138 percent and 250 percent of poverty.
• Children’s coverage losses were widespread, with 15 states showing statistically significant increases in the number and/or rate of uninsured children—Alabama, Arizona, Florida, Georgia, Idaho, Illinois, Indiana, Missouri, Montana, North Carolina, Ohio, Tennessee, Texas, Utah and West Virginia. Only one state—North Dakota—made positive progress.⁵
  

Child enrollment in Medicaid and CHIP, which together form the backbone of the health insurance system for children in low- to middle-income families, has also eroded.

• In 2018, Medicaid and CHIP provided comprehensive, pediatric-appropriate and affordable health coverage to nearly 37 million children under 19 (see Table 14).
• Following steady increases in child enrollment in Medicaid and CHIP since 2007, 2017 was the first year to not see an increase despite a strong economy. Child enrollment in Medicaid and CHIP decreased by over 828,000 between 2017 and 2018, a 2.2 percent decline in only one year.⁶
• Children in low- to middle-income families are more likely to be covered by Medicaid and CHIP than private insurance.⁷
• These programs provide lifelong benefits that far outweigh the short-term costs. The National Bureau of Economic Research compared children eligible for Medicaid during childhood with those not eligible and found Medicaid-eligible children were more likely to attend college and make greater contributions as adult taxpayers.⁸
  

Health coverage for parents also makes a difference for children. When parents have health coverage, their children are more likely to have health coverage. For every 1,000 infants born in 2017, 6 died before their first birthday (see Table 16).⁹ Continuing to expand coverage to low-income parents would help decrease the number of uninsured children and allow more women to access prenatal care to help reduce infant mortality, but many states continue to choose not to expand Medicaid coverage to more adults or to impose work requirements that push vulnerable families off of coverage.¹⁰

• A child is eight times more likely to have public health insurance if their parent has it.¹¹
• States that have expanded Medicaid coverage to parents have higher Medicaid participation among children. Massachusetts’ coverage expansion for parents cut the rate of uninsured children in half.¹²
• While 32 states and the District of Columbia have expanded Medicaid to very low-income parents and adults under the ACA’s expansion option,¹³ 18 states have not done so as of January 2020 (see Table 15).
• States that have not expanded Medicaid to parents and other adults under the Affordable Care Act
  have seen increases in their rate of uninsured children three times as large as states that have.
  

The increase in uninsured children and decrease in Medicaid and CHIP enrollment has been attributed to a number of factors, including unnecessary paperwork and bureaucratic red tape that make it harder for families to enroll or renew their eligible children in Medicaid or CHIP. Sometimes, paperwork is ignored even when families do enroll or renew, which was ultimately the reason Abel and his brother Jacob lost coverage. But these factors also include attempts to repeal the ACA and deeply cut Medicaid, such as cutting outreach and enrollment funds, eliminating the ACA’s individual mandate penalty and creating a pervasive climate of fear and confusion for immigrant families. The latter has left many of these families reluctant to enroll their citizen children in public coverage for fear of having it held against them or seeing their families ripped apart.

Continuous health coverage is essential for children. We must continue to expand—not limit—children’s access to coverage and care. No  family should face bankruptcy when a child breaks a bone, gets sick or faces a serious, life-threatening illness like Abel.