The State of America’s Children® 2021
CHILDREN LOST HEALTH INSURANCE BETWEEN 2016 AND 2019.
All children need access to comprehensive, affordable health coverage that is easy to get and to keep. Yet, even before our country began facing a devastating pandemic that has left more than 28 million Americans infected with the coronavirus, including more than 3 million children, our children were losing access to the health coverage they need to survive and thrive at an alarming rate.1
Decades of hard-fought progress to expand access to comprehensive, affordable health and mental health coverage through expansions of Medicaid, the Children’s Health Insurance Program (CHIP), and the Affordable Care Act brought the rate of uninsured children in America to an historic low. However, over the course of the last three years, our nation has shamefully reversed course and the number of uninsured children in America continues to steadily increase.2
- In 2019, an estimated 5.7 percent of children under age 19 (nearly 4.4 million) were uninsured—an increase of 320,000 more children without health insurance since 2018 (see Table 13). This is the third year in a row the number of uninsured children has grown and it is the largest annual increase in more than a decade.3
- This data also highlights continued and worsening disparities in health insurance coverage. The rates of uninsured children were especially high among Hispanic children, undocumented children, children living in the South, and children in families with lower incomes; and these children were among those that experienced some of the greatest increases in uninsured rates between 2018 and 2019.4
- This means millions of children and families lacked health insurance even before the rapid spread of the COVID-19 pandemic and the beginning of the economic crisis where many parents became unemployed and lost access to job-based health insurance. While fortunately, some of these children may be eligible for Medicaid and CHIP, it is but certain that many of them are going uninsured.5 In 2018, more than half (57.4 percent) of uninsured children were eligible for Medicaid or CHIP, demonstrating the critical need for outreach and enrollment efforts.6
Unfortunately, this is far from surprising given sustained efforts over the last four years by the Trump administration to undermine the public health insurance system, including Medicaid and CHIP, which form the backbone of the health insurance system for children in low- to middle-income families, as well as the administration’s anti-immigrant rhetoric and policies which have led many families to remove their eligible children—many of them U.S. citizens—from the health coverage they need out of fear of repercussions.7
- In 2019, Medicaid and CHIP provided comprehensive, pediatric-appropriate and affordable health coverage to more than 36 million children under 19 (see Table 14).
- More than half of American Indian/Alaska Native, Black, multi-racial, and Hispanic children rely on Medicaid and CHIP as their source of health coverage.8
- 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—and those numbers have only gotten worse in subsequent years. Child enrollment in Medicaid and CHIP decreased by 821,000 between 2017 and 2018 and decreased by 224,000 between 2018 and 2019.9
- Children in low-income families are far more likely to be covered by Medicaid and CHIP than private insurance. In 2019, 72 percent of children in low-income families had public health insurance coverage, including Medicaid, CHIP, Medicare, and TRI-CARE.10
- These health insurance 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.11
We know that 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 more economically secure and more likely to contribute to their communities.12 As children are losing coverage at staggering rates, there will be long-term consequences for their health and well-being.
When parents have health coverage, their children are more likely to have health coverage.
- A child is eight times more likely to have public health insurance if their parent has it.13
- States that have expanded Medicaid coverage to parents have higher Medicaid participation among children. For example, Massachusetts’ coverage expansion for parents cut the rate of uninsured children in half.14
- While 33 states and the District of Columbia have expanded Medicaid to very low-income parents and adults under the ACA’s expansion option, 12 states have not done so as of October 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 nearly three times as large as states that have.15
- Lack of health coverage—as well as inequities in our healthcare system and disparities in social determinants of health—have devastating impacts on our nation’s infants and mothers.16 The maternal mortality rate is higher now than it was decades ago, and Black women are bearing the brunt of this crisis.17 What’s more, for every 1,000 infants born in 2018, six died before their first birthday (see Table 16). Continuing to expand coverage to low-income parents through the ACA’s Medicaid expansion would help decrease the number of uninsured children as well as ensure more women access to essential prenatal care to help reduce both maternal and infant mortality.18
Children Are Not Immune
Although COVID-19 infection and death rates may be lower for children when compared to adults, our children are certainly not immune—to the virus itself or the racial inequities it is magnifying.
- As of February 25, 2021, 3,168,274 total child COVID-19 cases have been reported, representing 13.1 percent of all cases. Children were 0 to 0.19 percent of all COVID-19 deaths in the states that provided data (Note: only 43 states provided data on the age distribution of COVID-19 deaths).19
- CDC reports show that between February and July 2020, 78 percent of children who died from COVID-19 were Hispanic, Black, and American Indian children, though they represent only 41 percent of the population.20
These disparities mirror the disparities we see among adults and reflect decades of structural racism and injustice that have created a long history of social and economic inequities.21 Long before COVID-19, children of color were more likely to experience harmful environmental factors and toxic stress, grow up with underlying health conditions, and experience inequitable health care into adulthood including racial bias, discrimination, and inadequate treatment.22 Amid the pandemic, children of color are more likely to live with essential workers; experience crowded housing conditions, food insecurity, and wealth gaps; and face additional barriers to accessing high-quality, non-discriminatory health care—inequities that put the health and well-being of Black, Hispanic, and American Indian children at risk during a public health crisis.23
In addition to COVID-19 cases, the pandemic has created further child health concerns as well. Children are missing routine well-child visits that include important developmental screenings and vaccinations: compared to March through May 2019, there have been 3.2 million fewer child screening services, 6.9 million fewer outpatient mental health services, and 1.7 million fewer vaccinations for children ages zero to two through Medicaid and CHIP.24 Even with the need to continue to social distance and limit potential exposure, ensuring children have access to preventative services is critical in order to prevent further health concerns. Vaccines save lives and are critical in order to keep children safe from preventable diseases and ensure against the added crisis of a preventable outbreak amid the ongoing pandemic.