Urban Institute: Number of uninsured children fell during COVID-19, but progress could stall when pandemic protections expire

By Cameron Evans / June 30, 2022

The annual rate of uninsured children fell during the pandemic from about 5% in 2019 to about 4% in 2021, which translates to about 700,000 fewer uninsured children, according to a new report published Wednesday by the Urban Institute.  

The pandemic and associated job losses had the potential to increase uninsurance among American families and therefore increase children's coverage losses, but public coverage increased among children from early 2019 to early 2021, according to the report.

The report used data from the National Health Interview Survey (NHIS) and the Current Population Survey (CPS) Annual Social and Economic Supplement as well as data on children’s enrollment in Medicaid and the Children’s Health Insurance Program (CHIP) and ACA marketplace coverage through early 2022.

The report found that children’s uninsurance rates were relatively stable between early 2019 and early 2021 based on NHIS and CPS data. NHIS data suggest a decline in uninsurance among children between early and late 2021.

The report examines changes between early 2019 and early 2021 to reflect the first year of the pandemic and the first round of pandemic recovery legislation passed in March 2020. It also examines changes from early 2021 through late 2021 and early 2022 to reflect continuing trends and initial responses to the second major federal recovery effort in March 2021.

Policies such as the continuous coverage provision in the Families First Coronavirus Response Act, which has prohibited states from disenrolling people from Medicaid during the COVID-19 public health emergency since March 2020, appear to have limited the pandemic’s effects on children’s coverage rates, according to the report.

Enhanced ACA marketplace subsidies under the American Rescue Plan Act, passed in March 2021, and other economic recovery efforts may have also helped protect children’s insurance coverage. Together, the report suggests that those provisions may have contributed to a decline in uninsurance by the end of 2021.

“The decline in children’s uninsurance observed on the NHIS is remarkable given the economic downturn, and if it is confirmed by other federal surveys, policymakers will have a better understanding of which policies can successfully mitigate coverage losses during recessions,” the report states.

However, the report also states that children’s uninsurance could once again increase in 2022 and beyond without federal and state actions to maintain the enhanced marketplace subsidies and limit coverage losses when the continuous coverage requirement expires.

“Whenever this continuous coverage provision expires, the states are going to have to reassess eligibility for everyone who's enrolled,” said Jennifer Haley, one of the study authors, in an interview with Fierce Healthcare. “It’s going to be important that states are really careful about the unwinding of the requirements.”

Haley said there are other recommendations for states to try to reduce coverage loss when the continuous coverage provision ends, such as making sure state agencies know how to reach and notify people and making sure it’s easier for people to connect to the marketplace.

The NHIS indicates a significant 4.9 percentage-point increase in public coverage and a roughly corresponding decline in private coverage over the period. Changes in coverage on the CPS are not statistically significant but suggest offsetting public coverage gains and private coverage losses between March 2019 and March 2021.

Administrative data show that approximately 4 million more children were enrolled in Medicaid/CHIP in March 2021 than in March 2019 and indicate further gains in Medicaid/CHIP and Marketplace enrollment among children between early 2021 and early 2022.