VISIT STATE HEALTH COMPARE
Blog & News
Walsh, Elliot
Hest, Robert
Lukanen, Elizabeth
What Do the New Census Data Say About Insurance Coverage for Children and Adults? A Look at Both the National and State Level (SHVS Cross-Post)
November 01, 2024:
The following Expert Perspective (EP) is cross-posted from State Health & Value Strategies.
Authors: Elizabeth Lukanen, Elliot Walsh, Robert Hest, SHADAC
Original posting date October 30, 2024. Find the original post here on the SHVS website.
Background on Census Data
Every fall, the U.S. Census Bureau releases detailed data on the population, including data on health insurance coverage. The American Community Survey (ACS) is the premier source for detailed state and substate data on income, poverty, disability, marital status, education, occupation, travel to work, disability, and health insurance coverage, among other topics. An important feature of the ACS is that it includes a large enough sample for estimates for all 50 states and the District of Columbia and, in most states, there is sample to explore data disaggregated by insurance coverage type, age, race/ethnicity, and more.
2023 Data Do Not Capture the Full Impact of Coverage Changes Related to Medicaid Unwinding
The new, full-year 2023 insurance estimates from the ACS reflect data collected from January 1, 2023 to December 31, 2023. This health insurance coverage data provide new national- and state-level insurance coverage estimates, but do not fully reflect the Medicaid unwinding.
According to administrative data from the Centers for Medicare & Medicaid Services, Medicaid and Children’s Health Insurance Program (CHIP) enrollment declined by 13.9 million between March 2023 and June 2024. Some of those who disenrolled likely transitioned to other coverage, and others may have become uninsured. However, coverage transitions that happened in 2024 are not captured in the 2023 estimates from the Census Bureau. Because of the large changes in Medicaid and CHIP coverage during the unwinding, compared to the current, on-the-ground reality in 2024, these 2023 coverage estimates likely overestimate rates of public coverage and potentially underestimate rates of uninsurance.
Despite this limitation, the data are still instructive about changes to coverage during the early months of the unwinding period and generally for the year 2023. This expert perspective looks at health insurance coverage estimates at the national and state levels, and examines children’s health insurance coverage, looking at children’s uninsurance rates by state and by income level. As more data are released SHADAC will conduct additional analyses, presenting coverage estimates across key demographic categories, including by race/ethnicity. Disaggregating data is critical to identifying inequities and gaps in coverage, informing policies to improve equity and to prevent new disparities. It is also vital for identifying state policies and practices effective in maintaining coverage for specific populations so that they might be adopted in other states.
Overall Uninsurance Rates Were Fairly Stable
The uninsurance rate in the U.S. remained unchanged from the previous year, sitting at 7.9% in 2023. This was mirrored by stability in uninsurance in the states. From 2022 to 2023, the uninsured rate fell in 11 states and increased in three states – Iowa, New Jersey, and New Mexico (these changes were statistically significant). Table 1 below highlights the states with the highest and lowest rates of uninsurance in 2023.
Table 1. States with the Highest and Lowest Rates of Uninsurance, 2023
|
Highest Rates of Uninsurance |
Lowest Rates of Uninsurance |
||
|---|---|---|---|
|
Texas |
16.4% |
Massachusetts |
2.6% |
|
Georgia and Oklahoma |
11.4% |
District of Columbia |
2.7% |
|
Nevada |
10.8% |
Hawaii |
3.2% |
|
Wyoming and Florida |
10.7% |
Vermont |
3.4% |
|
Alaska |
10.4% |
Minnesota |
4.2% |
Source: SHADAC analysis of U.S. Census Bureau 2022 and 2023 American Community Surveys. Click here for data from all states.
Children’s Uninsurance Rates Increased
Notably, while the overall uninsurance rate remained stable between 2022 and 2023, the rate for children went up slightly (rising from 5.1% in 2022 to 5.4% in 2023). This comes after two years of falling rates of uninsurance for kids.
Five states saw an increase in their uninsured rate for children (Alabama, Louisiana, New Mexico, South Carolina, and Texas). This wasn’t clearly driven by changes in private or public coverage, though, as both remained stable nationally and went up and down in a variety of states.
Texas is the only state where the data tell a clear story — there was a decline in public coverage for children (1.9 percentage point (PP) decrease to 36.8% in 2023) and an increase in uninsurance for children (1.0 PP increase to 11.9%).
Insurance Coverage Changes for Children (Birth Through Age 18), 2022 to 2023
Source: SHADAC analysis of U.S. Census Bureau 2022 and 2023 American Community Surveys.
Low-Income Children Saw Declines in Public Coverage
For U.S. children below 200% of the Census poverty threshold, uninsured rates rose by 0.4 PP to 7.3% in 2023 (see Figure 1 below). This significant increase was likely driven by a 0.6PP decrease in public coverage (bringing that national rate down to 72.6% in 2023) and a statistically unchanged rate of private coverage (27.0%).
Note: Low income children are defined as those below 200% of the Census poverty threshold. Source: SHADAC analysis of U.S. Census Bureau 2022 and 2023 American Community Surveys.
Among the states, Louisiana (+1.5PP), Michigan (+1.2PP), South Carolina (+1.6PP), and Texas (+1.5PP) all saw significant increases in uninsurance for low-income children, rising to 5.5%, 4.3%, 8.0%, and 15.4%, respectively. No states saw decreases in uninsurance rates for low-income children.
These increases in children without coverage are likely tied to declines in public coverage for low-income children. 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%.
Health Equity Implications
Rising uninsurance rates for children, particularly for low-income children, has a number of implications for health equity. First, it is important to address the likely reason that uninsurance rates for low-income children rose. While the ACS data doesn’t collect information on the reasons for coverage transitions, the data suggests this was driven by declines in public coverage that correspond with the end of the Medicaid continuous coverage requirement (this is supported by administrative data showing that more than 4.5 million children lost Medicaid or CHIP between March 2023 and June 2024, a reduction of almost 11%).
Second, the essential role Medicaid plays in providing health insurance to low-income children, the majority of whom are racial and ethnic minorities, must be acknowledged. Over 60% of children enrolled in Medicaid and CHIP identify as African American or Black, Hispanic, Asian American, Native Hawaiian and Other Pacific Islander, American Indian or Alaska Native, or multi-racial (State Health Compare, SHADAC, University of Minnesota, Accessed 10/10/2024). Declines in public coverage therefore disproportionately impact children of color. This is supported by early evidence that enrollees who identified as Hispanic or Black were twice as likely to report losing coverage because they could not complete the renewal process. SHVS will explore differences in coverage losses by race and ethnicity as more data are released.
Finally, Medicaid plays a critical role in children’s ability to access care – children with Medicaid or CHIP coverage report high rates of having a usual source of care and access to routine care. Further, evidence shows that they were as likely in the past 12 months to have seen a doctor, had a well child visit, and have had a dental exam as privately insured children. While having Medicaid does not erase the health inequity propagated by systemic racism it does improve access to important healthcare services and losing that coverage risks widening gaps in equity. As stated earlier, the full impact of the unwinding isn’t reflected in the latest data as it only includes the beginning months of the unwinding period. It will be important to revisit this once data from the entire unwinding period is released in order to get the full picture of coverage changes for this and other groups.
Blog & News
What Are Adverse Childhood Experiences (ACEs)? ACEs Definition, Data Challenges, and Resources
November 14, 2024:
Basics Blog Introduction
SHADAC has created a series of “Basics Blogs” to familiarize readers with common terms, concepts, and topics that are frequently covered.
Children’s health is impacted by a number of factors – family life and income, housing, neighborhood, nutrition, health care access and cost, amongst others.
Adverse Childhood Experiences (ACEs) is a broad term for a range of negative experiences people may experience as children that can have profound implications for their health. Sometimes ACEs may occur in the form of a single traumatic event, such as a violent incident, but ACEs may also be the result of recurring, lower-grade stress, such as continual food insecurity.
Many research studies conducted over the course of decades have found ACEs to be linked not only with short-term health implications for children, but also long-term health burden that can last well into adulthood. Unfortunately, they are quite common. One SHADAC brief reports that nearly half (46.3%) of U.S. children have experienced at least one adverse childhood experience, with the CDC reporting that 1 in 6 adults have experienced four or more ACEs in their childhood.
There is ample evidence that ACEs are linked to increased risk of chronic health conditions (asthma, chronic obstructive pulmonary disease, stroke, obesity, etc.), engaging in coping behaviors with health risks (drug use, heavy drinking, unprotected sex, etc.), and long-term behavioral and/or mental health issues (depression, anxiety, substance use disorders, etc.). Evidence also shows that those who experience ACEs have poorer health outcomes, lower educational attainment, and higher unemployment rates.
In this blog, we will provide you with:
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Adverse childhood experience definition and examples
-
Data collection challenges
-
Comments on ACEs and health equity
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Resources on ACEs and related topics from SHADAC
Gaining a better understanding of ACEs can help people recognize them. With that knowledge, people can seek to prevent ACEs and seek health care that recognizes them as underlying risk factors that can influence people’s health. Understanding ACEs and disparities in their prevalence may help to improve public health and enhance health equity. We can work towards reducing the prevalence of childhood trauma and stresses that can comprise ACEs, as well as their impacts on health in both the short- and the long-term for different and diverse communities.
What Are Adverse Childhood Experiences?
First coined by Vincent Felitti, Robert Anda, and their colleagues in a study published in 1998, Adverse Childhood Experiences (ACEs) are defined by the CDC as, “potentially traumatic events that occur in childhood.”
There is no single, comprehensive definition of what experiences do and don’t constitute ACEs. Initial definitions focused heavily on childhood abuse and neglect, and dysfunction and violence in the household, but some experts have proposed broader definitions that encompass systemic issues, such as housing instability and food insecurity, which research suggests can have similar long-term health impacts.
Some examples of potential adverse childhood experiences include:
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Experiencing neglect or abuse (e.g., emotional, physical, sexual)
-
Separation from a parent, guardian, or caregiver due to death, incarceration or divorce
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Witnessing violence and/or domestic violence
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Family member attempting or dying by suicide
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Growing up in a household with substance abuse and/or mental health problems
-
Housing instability and food insecurity
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Peer-based bullying
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Experiencing or witnessing racism
These only represent a small number of what could be considered an adverse childhood experience.
ACEs and Health Equity
It has been established by a number of studies that certain populations experience ACEs at a higher prevalence. In the SHADAC study on ACEs and Health Equity, we found that, “Black children had the highest rate of ACEs exposure, at 63.7%, followed closely by American Indian and Alaska Native children, at 63.0%. Each of those was significantly different from the total population rate of 46.3%.”
Figure 1. Percent of children with one or more adverse childhood experiences by race and ethnicity, 2016-2019
The CDC reports groups with the highest prevalence of ACEs in the U.S. include:
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Women
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Racial and ethnic minorities (particularly American Indian or Alaska Native (AIAN) people and multiracial people)
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Members of the LGBTQ+ community
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Those considered low-income
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Those who are unemployed or can’t work
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Adults with less than a high school education
It follows, then, that these groups with a higher prevalence of ACEs would also experience the health impacts of these events at higher rates, which goes on to impact quality of life, overall health, and can impact the children of people in these groups as well. This can perpetuate a cycle of generational trauma and continue to widen the disparities between these and other groups.
It is also worth noting that even with the finding that these groups have higher prevalence of ACEs exposure compared to the total population, it could still be an overall underestimation of ACE prevalence because of demographic data collection challenges both for minority groups and for collection of ACE data in general.
You can learn more about demographic data collection and its impacts in the SHADAC brief on The Collection of Race, Ethnicity, Language Data on Medicaid Applications.
Adverse Childhood Experiences and Data Collection Challenges
As noted earlier, there are challenges when it comes to ACEs data collection.
One such challenge is who the data is collected from. Many surveys are filled out by a parent or guardian reporting on their child. This can result in underestimation of ACEs experienced by the child for a few reasons. Firstly, the parent or guardian filling out the survey could be unaware of a traumatic experience their child has had. Additionally, the parent or guardian could feel uncomfortable or unable to report that their child has had certain adverse experiences, like abuse or experiencing a parent’s mental health issues.
If a child is filling out the survey themselves, some of the questions may be inappropriate to ask of young children, the children may be reluctant to report some forms of trauma, or they may not even recognize that an event was a traumatic one.
As SHADAC researcher Colin Planalp mentions in his brief on ACEs and health equity, “Another approach [for data collection] could be to survey adults about their experiences as children, but that approach may also face some of the same limitations of reluctance to report some forms of trauma, and adults may simply not recall traumatic experiences that occurred decades ago. And by surveying adults about their own traumatic experiences as children, those data would by nature be retrospective— telling us little about the prevalence and types of ACEs among today’s children, which may change over time.”
Another issue is the feasibility of including all types of ACEs in a survey. As we mentioned in the previous section, we only listed a small number of possible ACEs. Surveys often condense or simplify the number of ACEs that it asks about – it simply isn’t feasible to list out every single type of ACE or trauma, which likely results in an overall underestimation of experienced ACEs in the population.
Adverse Childhood Experiences: Resources from SHADAC
Hopefully this has given you a general overview on the question, “What are ACEs?” But, as you could probably glean, this is a complex topic with many factors to consider and learn about. ACEs and their impact touch upon a number of issues, including health care cost & access, mental health care, housing, generational trauma, drug and substance use, structural oppression (like racism, homophobia, ableism, etc.), children’s health, and more. Each factor exists amongst and with the others, creating complex systems to unravel and intersectional identities to consider.
Additionally, this is a relatively new area of study, with that original Felitti et al. study published in 1998. New information and research continue to expand our understanding of ACEs, health disparities, and their impacts on health later in life – for example, a study published in Health Affairs in 2024 found a link between ACEs and adults experiencing financial and housing problems, social network problems, and food insecurity, and found that “those with ACEs had substantially higher [health care] utilization and 26.3 percent higher expenditures.”
Continued study and research can help us identify these issues, understand the groups impacted, and work towards both prevention and post-trauma support. Working on this issue has implications to improve the health of children and adults, reduce risk of chronic and mental health conditions, reduce related costs, and, hopefully, reduce the impact and prevalence of childhood trauma.
Keep learning about ACEs and related topics with some of the following SHADAC products:
Explore data on prevalence of Adverse Childhood experiences by state, demographic group, and more on State Health Compare. SHC also includes related measures, such as child poverty, and chronic disease prevalence, food insecurity, and more.
Issue Brief - The Kids Aren't Alright. Adverse Childhood Experiences and Implications for Health Equity
Presentation - Improving Health Equity Through Better Demographic Data Collection in Medicaid
Blog - Exploring Rising Uninsured Rates for Low-Income Children
Publication
Changing Dynamics in the Opioid Crisis Since the COVID-19 Pandemic
Soaring rates of fatal fentanyl, methamphetamine, and cocaine overdoses have worsened and spread to previously insulated groups, including teenagers and the elderly
It has been more than a decade since the U.S. Centers for Disease Control and Prevention (CDC) declared a national opioid “epidemic,” also known as the opioid crisis. In that time, hundreds of thousands of people have died, with the impact rippling out amongst friends, family, and communities: One in three U.S. adults know someone who has died of an overdose.1
Despite knowledge of this crisis and efforts to reduce fatal overdoses and impacts of substance use disorder, we have seen the opioid epidemic continually worsen and evolve. Evidence suggests that increased regulations on prescription opioids pushed many to illicit alternatives.2 The COVID-19 pandemic coincided with a huge increase in overdose deaths. Fentanyl, a once lesser-known contributor to the epidemic, has skyrocketed in its impact. Once insulated groups, like adolescents and the elderly, have seen overdose rates rise.
In this new brief from SHADAC, we examine changes in drug overdose death rates, and the types of drugs that cause these fatal overdoses, during the pandemic period (2019-2022). We also look at the history of the opioid epidemic: its beginnings, factors that influenced its evolution, and what it looks like now.
With this brief focusing on the four most common causes of drug overdoses — fentanyl, prescription opioids, methamphetamine, and cocaine — just some of the findings from this pandemic period include:
- Fatal overdoses from fentanyl increased 99%
- Fatal overdoses from methamphetamine increased 108%, and
- Fatal overdoses from cocaine increased 69%
While overdose death rates generally increased across all the measured racial and ethnic groups, “we […] found evidence of dramatic and growing disparities across racial and ethnic groups in rates of fatal overdoses, with the crisis increasingly harming American Indian and Alaska Native people and Black people during the pandemic era,” lead author and Senior Researcher Colin Planalp says.
In this brief, we explore these findings and more, including looking deeper at the impacts of the opioid crisis on different communities, demographics, and states. Click here to read the brief in full. The appendix for this piece is available here.
[1] Kennedy-Hendricks, A., Ettman, C. K., Gollust, S. E., Bandara, S. N., Abdalla, S. M., Castrucci, B. C., & Galea, S. (2024). Experience of Personal Loss Due to Drug Overdose Among US Adults. JAMA health forum, 5(5), e241262. https://pubmed.ncbi.nlm.nih.gov/38819798/
[2] Pitt, A.L., Humphreys, K., & Brandeau, M.L. (2018). Modeling Health Benefits and Harms of Public Policy Responses to the US Opioid Epidemic. American Journal of Public Health, 108(10), 1394-1400. https://ajph.aphapublications.org/doi/pdfplus/10.2105/AJPH.2018.304590
Blog & News
Understanding cannabis use and perceptions among Minnesota high school students
August 12, 2024:Most 9th and 11th graders report never having tried cannabis, but rates of recent use vary by demographic groups
In 2023, Minnesota became one of a growing number of states that have legalized cannabis for non-medical use by adults. When lawmakers crafted Minnesota’s legislation, they established a minimum age of 21 to use and purchase cannabis, similar to policies in other states that have legalized, and consistent with alcohol and tobacco policies.
The decision to limit legal access to cannabis to adults age 21 and older reflects common concerns about the potential for cannabis use to harm youth. While research on the public health implications of cannabis use is limited, studies have found associations between adolescent use of cannabis and a variety of negative outcomes, including lower educational attainment and worse school performance, as well as mental health and substance use disorders.1,2,3,4
Other states that legalized cannabis earlier and have had time to examine impacts of that legislation have generally not found clear increases in underage use since policies changed and legal sales began.5,6 Nevertheless, it will be important to monitor this issue in Minnesota, as experiences with alcohol and tobacco demonstrate that policies and enforcement matter when limiting substance use by youth.
Though commercial sales of legal cannabis in Minnesota aren’t expected to begin until 2025, researchers at the University of Minnesota School of Public Health’s Cannabis Research Center and SHADAC sought to get a head-start in understanding potential effects on youth. To do this, researchers began by studying youth experiences with and perceptions of cannabis and other substances prior to legalization. Our aim is to provide researchers, policymakers, and community members with key baseline evidence that can illuminate the current cannabis landscape, so it may be compared to post-legalization data in the coming years.
Cannabis and Other Substance Use Has Been Declining Among Youth in Minnesota
Using data from the Minnesota Department of Education’s Minnesota Student Survey, we produced estimates of the experiences and perceptions of Minnesota 9th and 11th graders (i.e., high school students) pertaining to cannabis, alcohol and tobacco, as well as some measures on nicotine-vaping products — a newer phenomenon for which less data is available.
Among the most important findings include:
- Almost 9 in 10 (86%) Minnesota high school students said in 2022 that they had never used cannabis, and the rate of students saying they had never used cannabis has been increasing over time.
- Less than 1 in 10 (8%) Minnesota high school students reported having used cannabis in the past month, but that percentage varied across demographic groups. For instance, only 3% of Asian students reported using cannabis in the past month, but 17% of American Indian and Alaska Native students reported they had used cannabis in the past month.
- Minnesota high school students appear to overestimate the prevalence of cannabis use by their peers. While half (50%) said they believed most of their peers use cannabis monthly, only 7% reported that they themselves use cannabis monthly — a similar pattern of apparent overestimation of substance use by peers as for alcohol and tobacco use.
More Research on Youth Use Necessary Once Legal Cannabis Sales Begin
The findings of our study are somewhat reassuring: despite the stereotype of teenagers experimenting with substances, most Minnesota high school students report they aren’t using cannabis — or alcohol, tobacco, and nicotine-vaping products.
However, even with 8% of Minnesota high school students reporting cannabis use, that represents tens of thousands of youth in the state. That is concerning, based on research that suggests various risks related to underage cannabis use.
Research from other states suggesting that legalization doesn’t necessarily lead to an unavoidable increase in underage cannabis use is reassuring, but we shouldn’t take that for granted. As cannabis policy continues to develop in Minnesota, and once legal sales of cannabis begin, it will be crucial to study youth cannabis use and to use those findings to fine-tune the state’s approach to minimize public health risks for youth.
Click here to read the full brief on this subject.
[1] National Academies of Sciences, Engineering, and Medicine. (2017). The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research. The National Academies Press. https://doi.org/10.17226/24625.
[2] Volkow, ND, Swanson, JM, Evins, AE, et al. (2016). Effects of Cannabis Use on Human Behavior, Including Cognition, Motivation, and Psychosis: A Review. JAMA Psychiatry. 73(3), 292-297. doi:10.1001/jamapsychiatry.2015.3278
[3] Winters, KC, Lee, CY. (2008). Likelihood of developing an alcohol and cannabis use disorder during youth: association with recent use and age. Drug and Alcohol Dependence. 92(1-3), 239-247. https://doi.org/10.1016%2Fj.drugalcdep.2007.08.005
[4] Tervo-Clemmens, B, Gilman, J, Evins, E. (2024). Substance Use, Suicidal Thoughts, and Psychiatric Comorbidities Among High School Students. JAMA Pediatrics. 178(3), 310-313. doi:10.1001/jamapediatrics.2023.6263
[5] Esie P, Ta M. (2024). Cannabis Use Among Students in Grades 8, 10, and 12, by Sex — King County, Washington, 2008–2021. MMWR Morbidity and Mortality Weekly Report. 73:27–31. https://www.cdc.gov/mmwr/volumes/73/wr/mm7302a1.htm
[6] Colorado Department of Public Health and Environment. (2022). CDPHE releases latest Healthy Kids Colorado Survey data. https://cdphe.colorado.gov/press-release/cdphe-releases-latest-healthy-kids-colorado-survey-data-0
Blog & News
Revised Childhood Vaccinations Measure on State Health Compare Shows Vaccination Rates Vary by State, Race/Ethnicity, and Insurance Coverage
January 30, 2024:Introduction
Childhood Vaccinations are an effective way to protect infants and young children from harmful diseases that can cause serious illness or death. Children are commonly vaccinated against a number of diseases, including chickenpox (Varicella), polio, hepatitis A and B, and measles, mumps, and rubella (MMR).
Despite the well-documented safety and efficacy of the vaccines, along with the endorsement of child vaccinations by the Centers for Disease Control and Prevention (CDC) and other public health authorities, rates of child vaccination lag in some portions of the United States. Monitoring trends in child vaccination rates can help explain why such gaps exist and inform efforts to improve child vaccination rates in the U.S.
A revised child vaccination measure on SHADAC’s State Health Compare (SHC) now presents annual, state-level vaccination rates for children aged 35 months, specifically the percent of those children who received the full series of recommended vaccines using data from the National Immunization Survey (NIS-Child) by survey year. This measure also presents these state-level rates by race and ethnicity, health insurance coverage type, and poverty level. In this blog post, SHADAC researchers highlight key findings from this new child vaccinations measure by race and ethnicity and type of health insurance coverage.
The Share of Children Receiving Recommended Vaccinations Has Been Relatively Stable, Though Large Variation Exists Across States
Nationally between 2017 and 2021, the share of children aged 35 months who had received the full schedule of recommended vaccinations remained relatively stable, remaining between 70% and 73% nationwide.
National Child Vaccination Rates, 2017–2021
However, while stable nationally, there was substantial state variation in the share of children who had received recommended vaccinations. For example, in 2021, the national child vaccination rate sat at 72.1%, but state-level rates ranged from as low as 56.6% in West Virginia to as high as 87.9% in Iowa. Also in 2021, six states (CT, IA, MD, MA, ND, and VT) had child vaccination rates of 80% or greater while West Virginia was the only state with a vaccination rate below 60%.
Top Five and Bottom Five State Child Vaccination Rates, 2021
| Top Five States | Iowa | 87.9% |
|---|---|---|
| Massachusetts | 85.4% | |
| Connecticut | 84.0% | |
| Vermont | 82.1% | |
| North Dakota | 81.3% | |
| United States | 72.1% | |
| Bottom Five States | West Virginia | 56.6% |
| Alaska | 61.3% | |
| Louisiana | 62.0% | |
| Arizona | 62.2% | |
| Georgia | 63.3% | |
Black Children, Hispanic/Latino Children, and Children of Other or Multiple Races Were Less Likely to Have Received Recommended Vaccinations Compared to White Children
Nationally, there were significant gaps in the share of children who had received the recommended vaccines by age 35 months by race and ethnicity.1
Non-Hispanic White children had the highest rate of vaccination at 75.5%, followed by children of multiple races or some other race (non-Hispanic) at 72.8%, Hispanic/Latino children (any race) at 69.9%, and, finally, African-American/Black children at 66.5%.
National Child Vaccination Rates by Race and Ethnicity, 2019–2021
There were also large gaps in rates of child vaccinations by race and ethnicity at the state level in 2019–2021, as shown in the table below. For example, in Michigan, African-American/Black children were nearly 30 percentage points less likely to have received the full schedule of recommended vaccinations compared to White children (49.8% vs. 79.3%). In the District of Columbia, Hispanic/Latino children were more than 20 percentage points less likely to have received the recommended vaccinations compared to White children (62.1% vs. 82.5%). And in North Dakota, children of some other race or multiple races were 20 percentage points less likely to have received the recommended vaccinations compared to White children (60.1% vs. 80.1%).
States with statistically significant gaps in child vaccination rates by race and ethnicity, 2019–2021
| State | White | African-American / Black | Hispanic / Latino | Other / Multiple Races |
|---|---|---|---|---|
| United States | 75.5% | 66.5%* | 69.9%* | 72.8%* |
| Dist. of Columbia | 82.5% | 68.1%* | 62.1%* | 70.8% |
| Georgia | 75.2% | 57.8%* | 69.8% | 70.8% |
| Illinois | 79.3% | 61.3%* | 66.9%* | 75.9% |
| Indiana | 73.1% | 66.0% | 59.1%* | 70.4% |
| Louisiana | 70.1% | 58.5%* | 69.3% | 71.9% |
| Maryland | 84.5% | 75.7%* | 71.4%* | 77.7% |
| Michigan | 79.3% | 49.8%* | 76.7% | 72.8% |
| Nevada | 76.4% | 55.8%* | 73.2% | 72.7% |
| New Jersey | 76.1% | N/A | 59.6%* | 72.2% |
| New Mexico | 76.6% | N/A | 67.7%* | 72.6% |
| New York | 69.8% | 69.0% | 67.0% | 79.5%* |
| North Dakota | 80.1% | N/A | N/A | 60.1%* |
| Oklahoma | 75.2% | N/A | 71.1% | 59.5%* |
| Rhode Island | 81.7% | N/A | 70.6%* | 83.1% |
| Tennessee | 75.9% | 49.4%* | 59.9%* | 76.6% |
| Texas | 71.0% | 61.7%* | 72.2% | 70.1% |
|
* Statistically significant difference (95% confidence level) in state estimate compared to Whites Source: SHADAC analysis of 2019–2021 NIS-Child microdata N/A indicates that data were not available or were suppressed due to statistical unreliability or small sample size |
||||
Health Insurance Coverage Matters for Rates of Child Vaccinations
Nationally, during the years 2020 through 2021, there were substantial gaps in the share of children who had received the recommended vaccinations by source of health insurance coverage. Children with private coverage alone (e.g., employer-sponsored or direct-purchase coverage) had the highest rate of vaccination coverage at 80.3%. Children with some other insurance (Children's Health Insurance Plan [CHIP] coverage, Indian Health Service [IHS] coverage, military, or some other form of insurance alone or in combination with private insurance) had a vaccination rate of 70.7%. Children with any Medicaid coverage (alone or in combination with other coverage) had a vaccination rate of 66.2%, 14 percentage points lower than private coverage. Children with no health insurance coverage (i.e., uninsured) had by far the lowest vaccination rate at 50.0%, which is more than 30 percentage points lower than children with private coverage alone.
National Child Vaccination Rates by Coverage Type, 2020–2021
That national pattern holds across the states, though due to small sample sizes, there are few available state-level estimates for children with other insurance and uninsured children. The chart below compares rates of vaccinations for children with private coverage alone and children with any Medicaid coverage. Rates of vaccinations among children with Medicaid were lowest in Alaska at 53.1% and highest in Connecticut at 81.1%. Child vaccination rates among children with Medicaid were at or below 60%in five states—AK, CO, KS, LA, and NJ—and were at or above 80% in just two states—Connecticut and Iowa. Rates of vaccinations among children with private coverage alone ranged from the lowest at 74.2% in Minnesota to the highest at 90.3% in Iowa.
In 35 states, children with any Medicaid coverage were less likely to have received recommended vaccinations compared to children with private coverage alone. Colorado had the largest percentage point gap between children with private coverage alone and any Medicaid coverage at 23.4 (82.4% vs. 59.0%), while Nebraska had the smallest gap at 1.5 percentage points (not statistically significant, 79.8% vs. 78.3%).
Data and Methods
Estimates of child vaccination rates represent the share of children aged 35 months who have received all recommended vaccinations, including the full series of DtaP, poliovirus, measles-containing, Hib, HepB, varicella, and PCV vaccines, which together provide protection against diphtheria, pertussis, tetanus, poliovirus, measles, mumps, rubella, hepatitis b, haemophilus influenza b, chicken pox, and pneumococcal infections.
Data in this post come from SHADAC’s revised Child Vaccinations measure on State Health Compare, which are based on our analysis of National Immunization Survey-Child (NIS-Child) microdata produced by the Centers for Disease Control and Prevention.
Three years of data were pooled to produce estimates by race and ethnicity; two years of data were pooled to produce estimates by coverage type. In both cases, this was done to increase sample sizes at the state level for smaller populations and to increase the number of statistically reliable state estimates. Estimates represent an average for these periods.
Note that the data source used in this analysis (NIS-Child) does not make data by more detailed race and ethnicity categories available. It is likely that these available categories conceal important differences within the aggregate groups, particularly the “some other race / multiple races” category. This group is likely to be primarily composed of children of different racial and ethnic groups in different states. Further, estimates were not available for all states for all racial and ethnic groups due to small sample sizes, even when pooling multiple data years.
Unless otherwise specified, all differences described in this analysis are statistically significant at the 95% level of significance.
1 Race lacks a genetic basis—it is socially constructed based on skin color and “apparent” physical differences. While race is socially created, it does have real social meaning and implications for health and well-being, including access to important health care services, such as vaccinations.
