Though the coverage provisions of the Affordable Care Act (ACA) were designed to reduce uninsurance rates among nonelderly adults, which were substantially higher than those for children (Heberlein et al. 2012), the ACA also included several policy changes implemented in 2014 with implications for children’s coverage. The Medicaid expansion to parents, tax credits for plans available in the new health insurance Marketplaces, health insurance market reforms, and the individual mandate were expected to lead to increases in health insurance coverage among children, particularly among those who were eligible for Medicaid or the Children’s Health Insurance Program (CHIP) but not enrolled (Kenney et al. 2011).
Before the ACA’s passage in 2010, uninsurance rates had been falling for children but increasing for nonelderly adults; underlying the declining uninsurance rates for children were increases in public coverage through both Medicaid and CHIP (Rosenbaum and Kenney 2014). The passage of CHIP in 1997 increased access to public coverage among children through both the expansion of eligibility and programmatic changes aimed at increasing enrollment of eligible children. The reauthorization of CHIP in 2009 led to additional eligibility expansions and policies aimed at further reducing uninsurance among low- and moderate-income children (Harrington et al. 2014). In 2013, public coverage was much more expansive for children than for nonelderly adults; half of the states had Medicaid/CHIP thresholds at 250 percent of the federal poverty level (FPL) or higher, and just four states had thresholds below 200 percent of FPL (Heberlein et al. 2013).
Multiple surveys have found that children experienced increases in health insurance coverage since 2013 following the implementation of the ACA’s major coverage provisions (Alker and Chester 2015; Martinez, Cohen, and Zammitti 2016; State Health Access Data Assistance Center 2016). In related work, we analyzed data from the Urban Institute’s Health Reform Monitoring Survey, which has been tracking coverage and other outcomes since 2013, and found small increases in coverage for children through September 2015 as well as improvements in access and affordability (Karpman, Gates, and Kenney 2016). In this brief, we use data from the National Health Interview Survey (NHIS) to place the uninsurance rate for children through September 2015 in the context of trends for children back to 1997 when CHIP was enacted. We also examine trends for children in different age groups and explore the characteristics and health care experiences of the remaining uninsured children in 2014. Subsequent briefs will provide updated estimates for children as more current data become available and will consider how coverage and related outcomes are changing for parents and within families.
Data and Methods
This analysis uses nationally representative data for the civilian noninstitutionalized population from the NHIS, which is conducted annually by the National Center for Health Statistics. The NHIS consists of three main sections: the family core, sample adult core, and sample child core. Questions on the family core are answered for each member of the family by a knowledgeable adult and include basic demographic information, educational attainment, employment status, general health status, and detailed information on health insurance coverage. Questions on the sample child and sample adult core are asked of one random child age 17 or under (if present, excluding emancipated minors) and one random adult over age 17. The sample child and sample adult core include more extensive information on health status and details on health care access, use, and affordability. In 2014, the NHIS included data on approximately 30,000 children and 13,000 sample children. The NHIS is fielded continuously throughout the year and can provide nationally representative annual or quarterly estimates. We use public use data from the 1997–2014 Integrated Health Interview Series, which provides harmonized versions of NHIS variables across years.1 For 2015 estimates, we use January through September 2015 NHIS data obtained through the NHIS early release program at the National Center for Health Statistics Research Data Center.2
We use data from 1997 to 2015 to track uninsurance counts and rates for children age 18 and under and by age group (age 5 and under, ages 6 to 12, and ages 13 to 18). Children are considered uninsured if they do not have coverage through private health insurance, Medicare, Medicaid, CHIP, military health insurance, or other public insurance at the time of the survey. For our analysis, we construct health insurance units (HIUs), which better reflect the units used to determine health insurance eligibility than does the broader family definition the NHIS uses. We examine changes between 2013 and 2014 in the composition of uninsured children and rates of uninsurance among children by age (age 5 and under, ages 6 to 12, or ages 13 to 18); race/ethnicity (non-Hispanic white, non-Hispanic black, non-Hispanic other race, or Hispanic); sex (male or female); health status (excellent or very good, good, or fair or poor); citizenship status; HIU income (less than 138 percent of FPL, 138 through 399 percent of FPL, or 400 percent of FPL and above); HIU work status (two full-time workers, one full-time worker, only part-time workers, no workers, or no adults3); highest HIU education (less than high school, high school graduate, some college, or college graduate); HIU citizenship (any noncitizen or no noncitizen in HIU); and census region (Northeast, Midwest, South, or West).
We also compare health care access, service use, and affordability experiences for uninsured children in 2014 to those for insured children. For these analyses, we define uninsured children as those who lacked health insurance coverage for all of the previous 12 months and insured children as those who had health insurance coverage for all of the previous 12 months. We construct four measures of access and service use, including having a usual source of care other than the emergency department, having had a routine checkup in the past 12 months, and indicators for having seen a specialist and a dentist in the past year. We also generate four measures of affordability. Using information reported by a family respondent, we identify children whose family had trouble paying medical bills in the past 12 months and a subset of children whose family was unable to pay their medical bills. We also measure the share of children who had any unmet need because of affordability in the past 12 months (including unmet needs for medical care, dental care, prescription drugs, eyeglasses, mental health care, specialist care, and follow-up care) and the share of children for whom medical care was delayed because of cost in the past 12 months. When assessing differences in these measures between uninsured and insured children, we adjust for individual and HIU characteristics including age, sex, race/ethnicity, highest level of educational attainment in the HIU, work status of HIU members, HIU income, child’s citizenship, region, reported health status, and activity limitations.
Changes in Uninsurance among Children
The uninsurance rate for children age 18 and under fell 67.9 percent between 1997 and the first three quarters of 2015, from 14.9 percent to 4.8 percent (figure 1). That decline in the children’s uninsurance rate occurred at a relatively steady pace and includes a significant drop following implementation of the ACA’s key coverage provisions from 7.1 percent in 2013 to 4.8 percent in 2015. Particularly notable is that the uninsurance rate fell during the Great Recession years (December 2007 through June 2009), a time when uninsurance rates for nonelderly adults increased. This demonstrates the countercyclical role that Medicaid and CHIP played in offsetting the loss of private coverage for children as the economy worsened (Holahan and Chen 2011).
Between 1997 and 2015, uninsurance was cut more than 60 percent for each of three children’s age groups, falling 75, 70, and 61 percent for children age 5 and under, ages 6 to 12, and ages 13 to 18, respectively (figure 2). For each age group, the share of children who were uninsured fell approximately 10 percentage points. Throughout this period, young children (age 5 and under) had the lowest levels of uninsurance despite their greater likelihood of living in low-income families (Jiang, Ekono, and Skinner 2015). In 2015, children ages 13 to 18 were more than twice as likely as children age 5 and under to be uninsured (6.7 percent versus 3.2 percent).
Figure 3 shows the estimated change in the number of uninsured children overall and by age group between 1997 and 2014. Approximately 4.4 million children were uninsured in 2014, down from 10.7 million in 1997. During this period, the number of uninsured children age 5 and under fell from 2.9 million to 1.0 million. More than two-fifths (1.9 million) of children who were uninsured in 2014 were between ages 13 and 18 and more than one-third (1.6 million) were between ages 6 and 12.
Composition of Children Remaining Uninsured in 2014
Table 1 shows the characteristics of uninsured children and their families in 2013 and 2014. A plurality of children who were uninsured in 2014 were Hispanic (43.6 percent); 38.7 percent were non-Hispanic white; and 8.9 percent were non-Hispanic black. Nearly one-sixth (15.6 percent) were noncitizens and one-third (35.2 percent) lived in a family with at least one noncitizen. Half of uninsured children (50.2 percent) lived in the South; another quarter (26.2 percent) lived in the West. The share of uninsured children living in the South increased slightly between 2013 and 2014, though this change was not statistically significant.
The share of uninsured children whose reported health status is fair or poor is small (1.7 percent), and just a slightly larger share (5.3 percent) had at least one activity limitation because of physical, mental, or emotional problems. More than half of uninsured children lived in families in which no one had more than a high school education; only one in five (20.1 percent) was in a family with at least one college graduate, although that share increased slightly between 2013 and 2014.
Fully 72.2 percent of uninsured children lived in a family with at least one full-time worker, and another 8.6 percent lived in a family with only part-time workers. Only 16.5 percent were in families with no working adults. The share of uninsured children living in families with two full-time workers increased from 15.5 percent in 2013 to 20.0 percent in 2014, and there was a corresponding, marginally significant decline in the share of uninsured children in families with only one full-time worker.
Despite the large share of uninsured children living with adults who work, 45.3 percent were in families with incomes below 138 percent of FPL (the eligibility threshold for the ACA’s Medicaid expansion for adults) in the previous year. Another 46.1 percent had family incomes between 138 and 400 percent of FPL (the income range targeted by the ACA’s premium tax credits for health plans sold through health insurance Marketplaces). Only 8.6 percent were in families with incomes above 400 percent of FPL, making these families ineligible for financial assistance to purchase coverage under the ACA.
Variation in Uninsurance Rates among Children
Uninsurance rates fell between 2013 and 2014 for most of the individual subgroups of children examined, but racial/ethnic, socioeconomic, and geographic disparities persist in coverage among children (table 2). Boys and girls experienced declines in uninsurance of 1.2 and 1.5 percentage points, respectively, and decreases in uninsurance were statistically significant for young children age 5 and under (from 5.0 percent in 2013 to 4.1 percent in 2014) and older children ages 13 to 18 (from 9.9 percent to 7.5 percent) but were not statistically significant for children ages 6 to 12. Though uninsurance rates fell for Hispanic children and non-Hispanic black children, 10.3 percent of Hispanic children were uninsured in 2014 compared with 4.2 percent of non-Hispanic white children and 3.7 percent of non-Hispanic black children. The decline in children’s uninsurance was statistically significant for those who were citizens but not among noncitizen children; nearly one-third (32.8 percent) of noncitizen children were uninsured in 2014 compared with 4.9 percent of citizen children. Statistically significant declines in uninsurance were reported for children in the Midwest and West. In 2014, uninsurance rates for children were lowest in the Northeast (3.7 percent) and Midwest (3.5 percent) and highest in the South (7.5 percent) and West (6.2 percent). The share of children with at least one activity limitation who did not have insurance declined from 5.4 percent in 2013 to 3.7 percent in 2014. Only children in excellent or very good health experienced a statistically significant decline in uninsurance between 2013 and 2014.
Uninsurance rates fell for children in families in which no one has a high school diploma or in which the highest level of education includes some college attendance but not a bachelor’s degree. However, uninsurance is strongly associated with the level of educational attainment in the family: 10.9 percent of children in families in which no one has a high school diploma are uninsured compared with 3.1 percent of children in families with one or more college graduates. Similarly, children are more likely to be uninsured if they live in families with no workers (6.6 percent) or only part-time workers (6.9 percent) than if they live in families with two full-time workers (4.3 percent). The uninsurance rate for children in families with at least one noncitizen was more than twice as high as the uninsurance rate for all children in 2014 (12.2 and 5.7 percent, respectively).
Finally, coverage gains were significant for children in families with incomes below 138 percent of FPL (from 9.5 percent uninsured in 2013 to 7.5 percent in 2014) and with incomes between 138 and 400 percent of FPL (from 8.5 percent to 6.9 percent). The uninsurance rate for children in families with incomes above 400 percent of FPL, which were not targeted by the ACA’s Medicaid expansion or Marketplace tax credits, were virtually unchanged and remained very low. In 2014, children in higher-income families were the least likely to be uninsured with only 1.8 percent lacking coverage.
Access, Service Use, and Affordability for Uninsured Children
For each of the measures of health care access, service use, and affordability examined here, children who were uninsured for the 12 months prior to the 2014 survey reported worse access than children who were insured for all of the previous 12 months (figures 4 and 5). Almost one in three uninsured children lives in a family that says they have trouble paying their medical bills, and 28.5 percent were reported to have some type of unmet health care need (including medical care, prescription drugs, dental care, eyeglasses, mental health care, follow-up care, or specialist care) because it was not affordable; 17.5 percent of insured children lived in families that had trouble paying their medical bills and 5.2 percent had an unmet need for care because of affordability. Reflecting their families’ greater challenges with affording health care, uninsured children were substantially more likely to have had a delay in receiving medical care in the previous 12 months because of the cost (17.7 percent versus 1.2 percent; figure 4).
One-third of uninsured children did not have a usual place for routine care. In contrast, 98.2 percent of insured children had a usual source of care. Just under half of uninsured children had a routine checkup and dental visit in the previous year (47.4 and 49.9 percent, respectively) whereas over 80 percent of insured children had had a routine checkup (85.8 percent) or dental visit (80.9 percent) in the previous year (figure 5).
These differences in access, affordability and service use remained after controlling for the demographic and socioeconomic characteristics of the children and their families (figures 6 and 7). Uninsured children were 20.7 percentage points more likely than insured children to have an unmet need for care because of affordability and 28.2 percentage points more likely to lack a usual source of care. Adjusted differences between uninsured and insured children also confirm that uninsured children are more likely to have families with trouble paying medical bills and who are unable to pay medical bills.
Taking into account the observed differences between insured and uninsured children, we also find that uninsured children were less likely than children with coverage to have had a routine checkup (32.9 percentage-point difference), a specialist visit (4.8 percentage-point difference), or a dentist visit (31.2 percentage-point difference) in the 12 months before the survey (figure 7).
This analysis shows that the uninsurance rate for children age 18 and under reached 4.8 percent in the first three quarters of 2015, a decline of 10.2 percentage points since 1997 including a 2.3 percentage-point drop since 2013. Much of the progress before 2013 was likely driven by expanded eligibility for Medicaid and CHIP as well as outreach efforts and improved policies to enroll and retain eligible children (Rosenbaum and Kenney 2014; Harrington et al. 2014). The underlying data indicate that additional gains in public coverage for children have occurred since 2013, but so have apparent gains in Marketplace coverage for children (data not shown). Other research finds that children living in states in which Medicaid was expanded for adults under the ACA experienced larger reductions in uninsurance between 2013 and 2014 relative to the states in which Medicaid was not expanded, which could indicate that the ACA’s Medicaid expansion to parents is having positive spillover effects on children’s coverage (Alker and Chester 2015).
Despite these gains in coverage among all children, however, some populations still face significant challenges. In 2015, for example, adolescents ages 13 to 18 had an uninsurance rate of 6.7 percent, which was more than double the rate for the youngest children age 5 and under. In addition, Hispanic children, those with a noncitizen in their family, and those with no high school graduates in their family each had an uninsurance rate above 10 percent in 2014.
Our analysis also confirms that the remaining uninsured children face large gaps in access to care, service use, and affordability of care compared with their insured counterparts. They are much less likely to have a usual source of care and to receive routine checkups and dental visits, and they are much more likely to have an unmet need for medical care because of affordability. Uninsured children are also more likely to live in families that have trouble paying or are unable to pay their medical bills. We find similar patterns in a companion brief that compares the health care experiences of insured and uninsured young children age 5 and under (Karpman et al. 2016).
Continued gains in coverage for children will require targeted outreach and enrollment efforts aimed at the subgroups with persistently higher uninsurance rates. But perhaps more importantly, further reductions in uninsurance among children may depend upon retaining children who enroll and reducing churning in and out of coverage and between programs. Looking ahead, we will continue to track coverage patterns for children as we approach yet another CHIP funding decision in 2017.
Moreover, monitoring access, service use, and affordability among all children will be important in the coming years. Although insured children fare much better than uninsured children, those with insurance still face some problems affording care and some gaps in service use. For example, in 2014 almost 20 percent of insured children lived in a family that had problems paying their medical bills, and a similar share had not seen a dentist in the past year. As the prevalence of higher cost-sharing plans continues to grow among employer and individual market plans and concerns about provider participation in Medicaid/CHIP and provider capacity persist, insurance coverage alone clearly does not guarantee access to affordable or high quality care.
- Minnesota Population Center and State Health Access Assistance Center, “Integrated Health Interview Series: Version 6.11. 2016,” accessed March 22, 2016, http://www.ihis.us.↩
- National Center for Health Statistics, “The National Health Interview Survey Early Release Program,” accessed March 25, 2016, http://www.cdc.gov/nchs/nhis/releases.htm.↩
- Most of these are older teens either living alone or without their parents or grandparents.↩
Alker, Joan, and Alisa Chester. 2015. Children’s Health Insurance Coverage Rates in 2014: ACA Results in Significant Improvements. Washington, DC: Georgetown University Health Policy Institute.
Harrington, Mary, Kimberly Smith, Christopher Trenholm, Genevieve M. Kenney, Lisa Clemans-Cope, Ian Hill, Kenneth Finegold, et al. 2014. CHIPRA Mandated Evaluation of the Children’s Health Insurance Program: Final Findings. Report submitted to the Office of the Assistant Secretary for Planning and Evaluation. Ann Arbor, MI: Mathematica Policy Research.
Heberlein, Martha, Tricia Brooks, Joan Alker, Samantha Artiga, and Jessica Stephens. 2013. Getting into Gear for 2014: Findings from a 50-State Survey of Eligibility, Enrollment, Renewal, and Cost-Sharing Policies in Medicaid and CHIP, 2012-2013. Washington, DC: Kaiser Commission on Medicaid and the Uninsured.
Heberlein, Martha, Michael Huntress, Genevieve Kenney, Joan Alker, Victoria Lynch, and Tara Mancini. 2012. Medicaid Coverage for Parents under the Affordable Care Act. Washington, DC: Georgetown University Health Policy Institute.
Holahan, John, and Vicki Chen. 2011. Changes in Health Insurance Coverage in the Great Recession, 2007-2010. Washington, DC: Kaiser Commission on Medicaid and the Uninsured.
Jiang, Yang, Mercedes Ekono, and Curtis Skinner. 2015. Basic Facts about Low-Income Children: Children under 18 Years, 2013. New York: National Center for Children in Poverty.
Karpman, Michael, Jason A. Gates, and Genevieve M. Kenney. 2016. Time for a Checkup: Changes in Health Insurance Coverage, Health Care Access and Affordability, and Plan Satisfaction among Parents and Children between 2013 and 2015. Washington, DC: Urban Institute.
Karpman, Michael, Jason A. Gates, Genevieve M. Kenney, and Stacey McMorrow. 2016. "Uninsurance among Young Children, 1997–2015: Long-Term Trends and Recent Patterns." Washington, DC: Urban Institute.
Kenney, Genevieve M., Matthew Buettgens, Jocelyn Guyer, and Martha Heberlein. 2011. “Improving Coverage for Children under Health Reform Will Require Maintaining Eligibility Standards for Medicaid and CHIP.” Health Affairs 30 (12): 2371–81.
Martinez, Michael E., Robin A. Cohen, and Emily P. Zammitti. 2016. Health Insurance Coverage: Early Release of Estimates from the National Health Interview Survey, January-September 2015. Hyattsville, MD: National Center for Health Statistics.
Rosenbaum, Sara, and Genevieve M. Kenney. 2014. “The Search for a National Child Health Coverage Policy.” Health Affairs 33 (12): 2125–35.
State Health Access Data Assistance Center. 2016. State Level Trends in Children’s Health Insurance Coverage. Minneapolis, MN: State Health Access Data Assistance Center.
About the Authors
Jason A. Gates is a research assistant in the Health Policy Center at the Urban Institute. His current work focuses on the effects of expanding coverage on low income populations, children and families. His expertise is with the National Health Interview Survey, and he has experience analyzing the American Community Survey and Behavioral Risk Factor Surveillance System. He received his BA from Dickinson College.
Michael Karpman is a research associate in the Health Policy Center at the Urban Institute. His work focuses on the implications of the Affordable Care Act, including quantitative analysis related to health insurance coverage, access to and affordability of health care, use of health care services, and health status. This work includes efforts to help coordinate and analyze data from the Urban Institute’s Health Reform Monitoring Survey. Before joining Urban in 2013, Karpman was a senior associate at the National League of Cities Institute for Youth, Education, and Families. He received his MPP from Georgetown University.
Genevieve M. Kenney is a senior fellow and codirector of the Health Policy Center at the Urban Institute. She has been conducting policy research for over 25 years and is a nationally renowned expert on Medicaid, the Children's Health Insurance Program (CHIP), and broader health insurance coverage and health issues facing low-income children and families. Kenney has led a number of Medicaid and CHIP evaluations, and published over 100 peer-reviewed journal articles and scores of briefs on insurance coverage, access to care, and related outcomes for low-income children, pregnant women, and other adults. In her current research, she is examining implications of the Affordable Care Act, how access to primary care varies across states and insurance groups, and emerging policy questions related to Medicaid and CHIP. She received a master’s degree in statistics and a PhD in economics from the University of Michigan.
Stacey McMorrow is a health economist with extensive experience using quantitative methods to study the factors that affect individual health insurance coverage and access to care as well as the impacts of state and national health reforms on employers and individuals. Her current work uses the Affordable Care Act and past Medicaid expansions to explore the effects of expanding insurance coverage on access to care, service use and health outcomes for various populations. Through this and other work, McMorrow has developed substantial expertise in analyzing data from several federal surveys, including the National Health Interview Survey and the Medical Expenditure Panel Survey. Other research interests include the role of community health centers and safety net providers under health reform, receipt of preventive and reproductive health services among women, barriers to care for low-income children, and the market-level effects of insurance expansions. McMorrow received her PhD in health economics from the University of Pennsylvania in 2009.
This brief was funded by the David and Lucile Packard Foundation and an anonymous donor. We are grateful to them and to all our funders, who make it possible for Urban to advance its mission.
The views expressed are those of the authors and should not be attributed to the Urban Institute, its trustees, or its funders. Funders do not determine research findings or the insights and recommendations of Urban experts. Further information on the Urban Institute’s funding principles is available at www.urban.org/support.