Walsh, Elliot
Hest, Robert
Stewart, Andrea

Children’s Health Insurance in 2023: Exploring Rising Uninsured Rates for Low-Income Children

• The total U.S. population
• Nonelderly adults (age 19-64), and 
• Children (age 0-18)

As seen in our full blog post on the 2023 ACS data release and our blog & infographic on the 2023 CPS data release, we found that overall rates of public coverage and private coverage remained unchanged in 2023. However, it is important to note that alongside that indicator of coverage stability at a national level, we also found that:

• Changes in uninsured rates for nonelderly adults' (age 19-64) varied depending on Medicaid expansion status and poverty level
• Rates of uninsured children (age 0-18) rose significantly

These findings sparked questions: After two years of falling rates, what could be contributing to rising uninsurance among children? Changes in nonelderly adults’ uninsured rates between 2022 and 2023 varied by poverty level and the status of Medicaid expansion in their state – could either of these factors also be impacting children’s uninsured rates in the newly released data?

While more research into causes behind these changes is needed, SHADAC began by looking at the ACS HI-11 tables, which include data specific to health insurance coverage rates for children below 200% of the Census poverty threshold. 

Keep reading to see some of our findings on how the insurance coverage of low-income children (those with family incomes below 200% of the Census poverty threshold) changed between 2022 and 2023 both nationally and at the state level.

Nationally, Children’s Uninsured Rates Increased while Public Coverage Rates Decreased

Looking at 2023 ACS data for children below 200% of the Census poverty threshold, we found that uninsured rates for this group mirrored overall trends at a national level, rising by 0.4 percentage points (PP) to 7.3%. This significant increase was likely driven by a 0.6PP decrease in public coverage (bringing that national rate down to 72.6%) and a statistically unchanged rate of private coverage (27.0%). 

Further, low-income children’s uninsured rate was 1.9PP higher than the 5.4% rate of uninsured children overall, a statistic which saw its own significant rise from 5.1% in 2022.

State-Level Coverage Changes for Low-Income Children

When we delve into state-level data for low-income children, we see that Louisiana (+1.5PP), Michigan (+1.2PP), South Carolina (+1.6PP), and Texas (+1.5PP) all saw significant increases in uninsurance, rising to 5.5%, 4.3%, 8.0%, and 15.4%, respectively.   

As with the national uninsured rate, our analysis found that a couple of these states mirror a simultaneous decrease in public coverage that likely influenced the increase in uninsurance. For example, Michigan saw a 3.1PP decrease in public coverage, bringing it down to 73.2%, and Texas saw a 2.5PP decrease in public coverage, bringing it down to 65.0%. 

Again, similar to trends at the national level, none of the states that saw increased uninsurance for low-income children saw any significant changes in private coverage among that group. 

No states saw decreases in uninsurance. 

Looking Closer at Public & Private Coverage Rates for Low-Income Children   

Looking at public coverage, states saw a wide range of changes:

• Four states, Arkansas (-4.8PP ), Michigan (-3.1PP), Nebraska (-5.4PP), and Texas (2.5PP), saw significant decreases in public coverage.
• Kansas (+4.5PP), Tennessee (+3.2PP), and Wyoming (+15.8PP) saw significant increases in public coverage

Looking at private coverage, states also saw a wide range of changes:

• Alaska (-8.1PP), Kansas (-5.3PP), Tennessee (-3.8PP), and Wisconsin (-4.9PP) all saw decreases in private coverage
• Kentucky (+3.4PP), Nebraska (+6.5PP), and New York (+2.5PP) all saw increases in private coverage

One thing to note here is that Nebraska, the state with the largest significant decrease in public coverage for low-income children, did not appear on the list of states with significant increases in uninsurance for the same group. But it did also see the largest increase in private coverage for this group, which could have mitigated any change in uninsurance.

Conclusion & Discussion 

By looking deeper into low-income children’s health insurance coverage in 2023, we hoped to find more information on why uninsured rates have increased both overall and specifically for this group. 

At the national level and in a small number of states, we observed increases in uninsurance that coincided with decreases in public coverage. This could be a result of the unwinding of the Medicaid continuous coverage requirement that began during 2023. According to an issue brief on children’s poverty and health insurance coverage published by KFF in January 2024, Medicaid covers 8 in 10 children living in poverty. This brief goes on to report that based on reported unwinding data from 23 states, almost 4 in 10 of those disenrolled from Medicaid during the unwinding are children, likely impacting the many children living in poverty with this public coverage.

However, this story of falling public coverage and rising uninsurance was not consistent across the states. We did not observe significant changes in uninsurance in most states, either because decreases in one type of coverage were offset by increases in another type of coverage, or because there was little movement in coverage overall. 

Coverage estimates for 2024 (to be released next fall) will give a more complete picture of coverage during the unwinding and may clarify how coverage evolved during this dynamic period.