Even as the Economy Grew, More Children Lost Health Insurance

The share of children with health coverage in the United States fell for the third consecutive year in 2019, according to census data, after decades of increases.

The decline occurred during a period of economic growth — before the coronavirus pandemic caused broad job losses that might have cost many more Americans their health insurance.

A report Friday by the Georgetown Center for Children and Families found that the ranks of uninsured children grew the most in Texas and Florida, and that Latino children were disproportionately affected. Nationally, the number of children without health insurance rose by 320,000 last year alone, to a total of nearly 4.4 million children, the report found.

“What’s so troubling about this data is we were making so much progress as a country,” said Joan Alker, the center’s executive director and an author of the report. “And now that progress is clearly reversing.”

The picture since the start of the pandemic is less clear. Many families have lost jobs that came with health coverage, which could increase the number of children without insurance. But national enrollment in Medicaid and the Children’s Health Insurance Program (CHIP) has also swelled, aided by temporary policies to prevent families from losing coverage during the emergency. More current estimates for the uninsured rates among children will take time.

In recent years, falling enrollment in Medicaid and CHIP drove the overall changes, according to the report. Although those programs for low- and middle-income children are primarily managed by state governments, Trump administration policies could be playing a role: The administration has encouraged states to check eligibility more often, which advocacy groups say has caused many families to lose coverage because of paperwork errors and missed deadlines.

And the administration’s policies on immigrant families have caused some to end enrollment for their children even though they are eligible citizens, according to child welfare groups in several states with the largest drops. In particular, the “public charge” rule makes it harder for immigrants to be approved for green cards if they have received public benefits or are deemed likely to receive them in the future.

“They were coming to me saying: ‘Please close my case. I don’t want to get into any trouble,’” said Graciela Camarena, outreach program director in the Rio Grande Valley for the Texas branch of the Children’s Defense Fund, a group that helps enroll children in health coverage. Ms. Camarena said most clients would not be affected by the public charge policy if they signed up their children, but news of the rule had produced widespread concern.

The public charge policy was completed last summer but has been put into effect unevenly. For months, its enforcement was paused in several states by a court order. More recently, its implementation has been softened because of the public health emergency related to the coronavirus. Nevertheless, Latino children saw a disproportionate drop in coverage through 2019, according to the Georgetown report, an indication that their families were reacting to the policy.

The public charge rule does not take into consideration benefits used by citizen children. But Alison Yager, deputy executive director of the Florida Health Justice Project, said the pandemic had made it hard for her nonprofit organization to get that fact and other accurate information about the public charge rule to worried families.

“It’s significantly hampering education efforts,” Ms. Yager said. “It seems to be harder to spread accurate information than misinformation once it has taken hold.”

A large body of evidence has shown that children’s health insurance coverage has long-term benefits for children and their families, improving health outcomes, educational attainment and even adult earnings.

Last year, some state and federal officials suggested it was good news that more than a million children were dropped from Medicaid and CHIP enrollment from December 2017 to June 2019, arguing that more Americans were getting coverage from employers in an improving economy. But census data seems to counter the notion that many families gained employer insurance: The rate of uninsured children increased in some states with declining Medicaid and CHIP enrollment, including Tennessee, Texas, Idaho and Utah. The 2019 data shows that trend has continued for another year.

The Georgetown report found that the states with the biggest 2019 increases in the uninsured rate among children — all more than 1.5 percentage points — were South Dakota, Texas, Utah, Arkansas, Missouri, Delaware, Arizona and South Carolina. More than half of uninsured children live in the South, where most of the states have declined to expand Medicaid under the Affordable Care Act. Ms. Yager said Florida’s refusal to expand Medicaid had kept many children uninsured, too, along with low-income adults.

She said of expanding Medicaid: “That would bring a whole lot of families into Medicaid coverage who are kind of hanging out there in the coverage gap. We know that in general, kids of insured parents are more likely to be insured themselves.”

According to the report, the uninsured rate in 2019 for children living in states that had not expanded Medicaid was 8.1 percent. That was almost double the rate (4.2 percent) in states that had expanded.

In all, Medicaid and CHIP cover about 36 million children; that is nearly half the total number of children in the United States.

It is still unclear precisely how the pandemic has changed the number of uninsured children. The Urban Institute has estimated that 2.9 million people younger than 65 will become uninsured by the end of this year as a result of the recession, including 300,000 children.

Child welfare groups say they are worried that even though recent enrollment declines appear to be reversing, many families who have recently lost their employer-based insurance may be unaware they can sign up for public benefits.

It will be harder for children who are already enrolled to lose Medicaid, though, because under the emergency funding bill that Congress passed in the spring, states cannot terminate people’s Medicaid coverage or tighten eligibility rules during the public health crisis.

Preliminary data from the Centers for Medicare and Medicaid Services (C.M.S.) shows that Medicaid and CHIP enrollment grew by 1.4 million children between February and June, more than the programs lost in the previous two years.

A spokeswoman for C.M.S. said the agency was “committed to ensuring that eligible children are enrolled and retained in coverage,” adding that it had provided $48 million in grants for outreach and enrollment efforts last year.

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