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Strengthen the Evidence for Maternal and Child Health Programs

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Evidence Tools
Uninsured

Introduction

This toolkit summarizes content from the Uninsured Evidence Accelerator and the MCHbest database. The peer-reviewed literature supporting this work can be found in the Established Evidence database. Use the resources below as you develop effective evidence-based/informed programs and measures.

From the MCH Block Grant Guidance. There is a well-documented benefit for children in having health insurance. Research has shown that children who acquire health insurance are more likely to have access to a usual source of care, receive well child care and immunizations, to have developmental milestones monitored, and receive prescriptions drugs, appropriate care for asthma and basic dental services.1 Serious childhood problems are more likely to be identified early in children with insurance, and insured children with special health care needs are more likely to have access to specialists.1 Insured children not only receive more timely diagnosis of serious health care conditions but experience fewer avoidable hospitalizations, improved asthma outcomes and fewer missed school days.1 The number of uninsured children in the United States decreased for many years, reaching the lowest percent in 2016 at 4.7%.2 However, between 2016 and 2018 the number of uninsured children increased by 12.5%,largely due to a decline in public coverage.2 From 2018 to 2020, the number of uninsured children increased by 1.6 percentage points for children living in poverty.3 As part of the public health emergency response to the COVID-19 pandemic, temporary changes to Medicaid and CHIP drove a decrease in the level of uninsured children, back down to 5.0%.4

Goal. To ensure access to needed health care services for children.

Note. Access other related measures in this Population Domain through the Toolkits page.

Overview: Read a summary of the issue related to Title V

Comprehensive, affordable health insurance is an essential element of a broader set of policies needed to promote children’s health and well-being.1 There have been significant strides toward insuring all children through the building of a public insurance framework robust enough to reach most children left out of workplace coverage.1 The prevalence of uninsurance among children has fluctuated due to policy changes, economic factors, and shifts in health care access.2 Children are insured either as dependents under an employer-sponsored health plan or through publicly funded insurance made available through Medicaid, the Children’s Health Insurance Plan (CHIP), or a subsidized health plan purchased through a Marketplace.1

Employer coverage is the dominant source of insurance among children in higher-income families.1 Lower- and moderate-income families without affordable employer coverage for their children tend to rely on Medicaid and CHIP.1 Medicaid also serves as a source of supplemental insurance for families with employer plans but whose children have serious health conditions requiring extensive, long-term care that exceeds plan coverage.1 Medicaid pays for nearly one in two U.S. births3 and, with CHIP, covers 38% of children,4 and acts as the primary funding source for the full range of pediatric care, including care for children and youth with special health care needs (CYSHCN) and those with disabilities.1 

In 2022, nearly one-quarter (24.5%) of uninsured children had not seen a doctor in the past year compared to 5.7% of children with private coverage, and 8.6% of uninsured children went without needed care due to cost compared to less than 1% of children with private coverage.5 On all measures of care, children who are uninsured persistently lag behind those children with public or private insurance:

  • Children with health insurance are more likely to have access to a usual source of car; receive well-child care and immunizations; have developmental milestones monitored; receive prescription medications, appropriate care for asthma, and dental services; and have fewer unmet needs compared to children without insurance.6,7
  • Serious health conditions are more likely to be identified and diagnosed early on for children with insurance and CYSHCN are more likely to have access to specialists when insured.6
  • Children with insurance experience fewer avoidable hospitalizations, improved asthma outcomes, and fewer missed days of school compared to children without insurance.6
  • Expansions of children’s public insurance have been found to increase financial stability and family material well-being in the short-run and long-run, decrease mortality and rates of chronic conditions among children, and lead to greater educational attainment and less reliance on government support later in life.8,9

In the last decade, notable coverage gains have occurred after implementation of the Affordable Care Act’s (ACA) coverage expansion in 2014 and Federal policies to support health insurance expansion during the COVID-19 pandemic, such as the Medicaid continuous enrollment provision, an increase in premium tax credits from the expanded Marketplace, and an extended Marketplace special enrollment period.1,10,11 On March 31, 2023, Medicaid ended its COVID-related continuous enrollment provision and states were required to review the eligibility of Medicaid enrollees, including children, during an “unwinding” process.12 As of May 14, 2024, 5.02 million children have lost Medicaid coverage.12

Children are more likely to be disenrolled due to procedural reasons and experience gaps in coverage before re-enrolling back onto Medicaid.12,13 Such disenrollments may widen racial and ethnic disparities with children of color making up a disproportionate share of Medicaid enrollees and many facing barriers to maintaining coverage.12 On April 2, 2024, the Centers for Medicare and Medicaid (CMS) released new eligibility regulations to address Medicaid unwinding over the next three years to help children enroll and stay enrolled in Medicaid and CHIP.14,15

Detail Sheet: Start with the MCH Block Grant Guidance

DEFINITION

Numerators:

Number of children, ages 0 through 17, who are reported by a parent to not be currently covered by any private or public health insurance

Denominators:

Number of children, ages 0 through 17

Units: 100

Text: Percent

HEALTHY PEOPLE 2030 OBJECTIVE

Related to Access to Health Services (AHS) Objective 01: Increase the proportion of persons with medical insurance. (Baseline: 89.0% of persons under 65 years had medical insurance in 2018, Target: 92.1%)

DATA SOURCES

Child Health and/or Adolescent Health

MCH POPULATION DOMAIN

Child Health and/or Adolescent Health

MEASURE DOMAIN

Social Determinants of Health

Data Sources: Learn more about the issue and access the data directly

This SM is measured through data collected from the American Community Survey (ACS) and the National Health Interview Survey (NHIS). According to NHIS data, the percent of children aged 0-17 who were uninsured decreased from 5.1% in 2019 to 4.2% in 2022.16 Public coverage increased from 2019 (41.4%) through 2022 (43.7%).16 No significant trend in private coverage was observed between 2019 (55.2%) to 2022 (54.3%).16

1. Accelerate with Evidence—Start with the Science

The first step to accelerate effective, evidence-based/informed programs is ensuring that the strategies we implement are meaningful and have high potential to affect desired change. Read more about using evidence-based/informed programs and then use this section to find strategies that you can adopt or adapt for your needs.

Evidence-based/Informed Strategies: MCHbest Database

The following strategies have emerged from studies in the scientific literature as being effective in advancing the measure. Use the links below to read more about each strategy or access the MCHbest database to find additional strategies.

Chart of Evidence-Linked Strategies and Tools

Evidence-Informed

Evidence-Based

Mixed Evidence

Emerging Evidence

Expert Opinion

Moderate Evidence

Scientifically Rigorous

 

 

Field-Based Strategies: Find promising programs from AMCHP’s Innovation Hub

Emerging:

Promising:

Best:

 

Key Findings and Emerging Issues: Read more from the literature

The following are key findings emerging from the literature:

  1. Simplifying enrollment procedures for health insurance programs can increase enrollment and reduce coverage lapses among eligible children. Streamlining applications through online platforms and automated renewals can address administrative barriers for families.32,33,34
  2. Community outreach and enrollment assistance provided by trusted sources like schools, healthcare providers, and community organizations are essential for reaching underserved populations and facilitating successful enrollment, by building trust and meeting families where they are.33,35,36
  3. Collaboration between healthcare providers and health insurance programs enhances the identification of uninsured children and links families to coverage during medical visits, with pediatricians playing a key role in education, referrals, and on-site enrollment.37,38
  4. Tailored outreach and support for diverse and vulnerable groups can effectively address distinct barriers related to language, culture, and healthcare needs, thus improving equity of access to health insurance and services.34,39
  5. Policies expanding Medicaid and CHIP eligibility, reducing premium costs, and mandating coverage can increase parental insurance and reduce uninsurance among low-income children.40,41

Research. Multiple strategies are emerging as potential approaches to advance this NPM, but haven’t been studied with enough rigor to be included in the evidence-based continuum. Additional research is needed to verify outcomes, but initial studies have shown promise of these strategies in MCH settings:

  • Establishing school-based health centers that provide comprehensive healthcare, including assistance with health insurance enrollment.42
  • Developing navigator programs to support families in navigating the insurance system.43
  • Launching targeted public awareness campaigns to inform parents and guardians about the availability and importance of children’s insurance coverage.44
  • Identifying and targeting specific hard-to-reach populations that experience increased prevalence of uninsurance among children.45

Research Gaps: Learn where more study is needed

Topical Area Knowledge Gaps. Lack of studies on:

  • Examining the effects of ending Medicaid continuous enrollment on insurance coverage, particularly for children from historically marginalized communities.
  • Understanding why parents choose not to enroll their children in available health insurance programs.
  • Investigating disparities in healthcare access among children with different insurance types.
  • Assessing the long-term effects of expanding children's public insurance on health and economic outcomes.

Specific Intervention Research Gaps. Lack of studies on:

  • Evaluating the effectiveness of culturally responsive and linguistically appropriate outreach strategies in increasing insurance enrollment among historically marginalized groups.
  • Investigating the impact of innovative insurance models, such as extending continuous Medicaid coverage for newborns until age five, on health outcomes and financial stability for children with special health care needs (CYSHCN) and their families.
  • Developing and testing strategies to prevent coverage losses and address widening disparities during the Medicaid "unwinding" process.

Methodological Gaps. Lack of studies on:

  • Quantifying the benefits of sustained insurance coverage throughout childhood.
  • Evaluating the effectiveness of outreach strategies for enrolling eligible uninsured children across diverse populations.

Strategy Video: Watch a summary of evidence-based/informed strategies

Watch a short video discussing state-of-the-art, evidence-based/informed strategies that can be used or adapted as ESMs. Experts in the field discuss approaches, the science, and specific ways that Title V agencies can implement and measure these approaches.

2. Think Upstream with Planning Tools—Lead with the Need

The second step in developing effective, evidence-based/informed programs challenges us to plan upstream to ensure that our work addresses issues early and is measurable in “turning the curve” on big issues that face MCH populations. Read more about moving from root causes to responsive programs and then use this section to align your work with the data and needs of your populations.

A. Move from Need to Strategy

Use Root-Cause Analysis (RCA) and Results-Based Accountability (RBA) tools to build upon the science to determine how to address needs.

Planning Tools: Use these tools to move from data to action

B. Align with the Needs of the Population

Consider the following findings related to this performance measure.

The Role of Title V: Get ideas on how to implement strategies

Title V can nurture partnerships with Medicaid to increase access to affordable, comprehensive coverage by:

  • Expanding Medicaid and CHIP Eligibility by exploring options such as increasing the mandatory income eligibility level for children under a combined Medicaid and CHIP benefit setting the mandatory minimum level nationwide to 300% of the Federal Poverty Level.1,28
  • Providing Outreach and Enrollment Assistance for Medicaid and CHIP by linking families to enrollment resources, assisting with enrollment, offering health education and promotion, and conveying culturally relevant messages.29,30
  • Ensuring Insurance Access and Improving Coverage and Funding for Care by improving mechanisms for public and private coverage for CYSHCN and investing in system improvements; and expanding access to Medicaid for CYSHCN by creating a reasonable, sliding scale, premium schedule for families at all income levels.31

SDOH and Health Equity Considerations: Identify ways to advance health for all

Health Equity

Health inequities are consequences of multiple socio-economic factors that are largely due to structural racism, income inequality, and poverty.11 A disproportionate number of children who lack insurance are Black, Latino, and American Indian/ Alaska Native.11 Children living in low-income households are also at higher risk for being uninsured.11 Medicaid and CHIP serve about half of all children, many of whom are members of racial and ethnic minority groups, have complex medical conditions, or are from low-income backgrounds.17-19

The American Academy of Pediatrics recommends 1) universal eligibility and 2) automatic enrollment for Medicaid/CHIP for all children (ages 0 to 26) lacking other sources of health insurance.19 Medicaid demonstration authority could also be used to encourage some states to test the impacts of a near-universal coverage approach for children combining automatic enrollment at birth and extended continuous Medicaid coverage for newborns until age five.1 Uniform eligibility levels and enrollment and retention policies may help ensure equitable and continuous access to coverage for all children.

Special Considerations: Tease out ways to zoom in on populations of focus

Lack of coverage among CYSHCN can have a severe impact on families.20,21 CYSHCN often require substantial and costly care from primary, specialty, and ancillary services to address chronic health concerns and out-of-pocket costs can be devastating to families.22,23,24 Once enrolled in public insurance coverage, Medicaid’s robust benefit package and cost-sharing protections can enable families to adequately and affordably meet their children’s complex health care needs.25 States and jurisdictions need to consider different pathways to eligibility for Medicaid coverage, and also identify those who are eligible, communicate the benefits to them, and ensure they receive optimal coverage.26

3. Work Together with Implementation Tools—Move from Planning to Practice

The third step in developing effective, evidence-based/informed programs calls us to work together to ensure that programs are movable within the realities of Title V programs and lead to health equity for all people. Read more about implementation tools designed for MCH population change and then use this section to develop responsive strategies to bring about change that is responsive to the needs of your populations.

Additional MCH Evidence Center Resources: Access supplemental materials from the literature

Implementation Resources: Use these field-generated resources to affect change

Practice. The following tools can be used to translate evidence to action to advance this NPM:

Partnership. The following organizations focus efforts on advancing health insurance coverage:

References

Introductory References: From the MCH Block Grant Guidance

1 Institute of Medicine (US) Committee on Health Insurance Status and Its Consequences. America’s Uninsured Crisis: Consequences for Health and Health Care. Washington (DC): National Academies Press (US); 2009. https://nap.nationalacademies.org/catalog/12511/americas-uninsured-crisis-consequences-for-health-and- health-care

2 Alker J, Roygardner L. The Number of Uninsured Children is On the Rise. Georgetown University Health Policy Institute, Center for Children and Families. 2019 October. https://ccf.georgetown.edu/wp- content/uploads/2019/10/Uninsured-Kids-Report.pdf

3 U.S. Census Bureau. Changes in Children’s Health Coverage Varied by Poverty Status From 2018 to 2020. 14 September 2021. https://www.census.gov/library/stories/2021/09/uninsured-rates-for-children- in-poverty-increased-2018-2020.html

4 U.S. Census Bureau. More Children Were Covered by Medicaid and CHIP in 2021. 13 September 2022. https://www.census.gov/library/stories/2022/09/uninsured-rate-of-children-declines.html

Toolkit References: From the Evidence Accelerator

1 Alker, J. C., Kenney, G. M., & Rosenbaum, S. (2020). Children’s Health Insurance Coverage: Progress, Problems, And Priorities For 2021 And Beyond: Study examines children's health insurance coverage. Health Affairs, 39(10), 1743-1751.
2 Mykyta, L., Keisler-Starkey, K., Bunch, L. (2022 September). Uninsured Rate of U.S. Children Fell to 5.0% in 2021 (census.gov). United States Census Bureau.
3 Heberlein, M. (2020). Medicaid's role in financing maternity care. Published online January, 16. (2020 January). Medicaid’s role in financing maternity care [Internet]. Washington (DC): Medicaid and CHIP Payment and Access Commission.
4 Henry J. Kaiser Family Foundation. (2018). Health insurance coverage of children 0–18. San Francisco (CA): KFF.
5 Williams, E. & Rudowitz, R. (2024 January). Recent Trends in Children’s Poverty and Health Insurance as Pandemic-Era Programs Expire | KFF
6 Institute of Medicine (US) Committee on Health Insurance Status and Its Consequences. (2009). America’s Uninsured Crisis: Consequences for Health and Health Care. Washington DC: National Academies Press.
7 Garfield, R., Orgera, K., Damico, A. (2019 January). The Uninsured and the ACA: A Primer – Key Facts about Health Insurance and the Uninsured amidst Changes to the Affordable Care Act – How does lack of insurance affect access to care? – 7451-14 | KFF
8 Adams, E. K., Johnston, E. M., Guy, G., Joski, P., & Ketsche, P. (2019). Children’s Health Insurance Program expansions: what works for families? Global Pediatric Health, 6, 2333794X19840361.
9 Wherry LR, Kenney GM, Sommers BD. The role of public health insurance in reducing child poverty. Acad Pediatr. 2016;16(3 suppl):S98-S104.
10 Fry-Bowers, E. K. (2021). The Affordable Care Act, COVID-19, and health care insurance for children. Journal of Pediatric Health Care, 35(6), 639-643.
11 Conmy, A. B., Peters, C., De Lew, N., & Sommers, B. D. (2023). Children’s Health Coverage Trends: Gains in 2020-2022 Reverse Previous Coverage Losses. Emergency (PHE), 19, 20.
12 Center for Children and Families. (2024). Unwinding Continuous Coverage – Center For Children and Families (georgetown.edu)
13 Alker, J., & Brooks, T. (2022 February). Millions of children may lose Medicaid: what can be done to help prevent them from becoming uninsured. Georgetown University, Center for Children and Families.
14 Serafi, K., & Mann, C. (2024 May). New Rules Will Help Adults and Children Enroll — and Stay Enrolled in — Medicaid and CHIP | Commonwealth Fund.
15 Centers for Medicare & Medicaid Services, Department of Health and Human Services (2024 April). Medicaid Program; Streamlining the Medicaid, Children’s Health Insurance Program, and Basic Health Program Application, Eligibility Determination, Enrollment, and Renewal Processes. 42 CFR Parts 431, 435, 436, 447, 457, and 600 [CMS–2421–F2] RIN 0938–AU00.
16 Cohen, R. A. & Cha, A. E. (2023). Health insurance coverage: Early release of estimates from the National Health Interview Survey, 2022 (cdc.gov)
17 Brooks, T., & Gardner, A. (2020). Snapshot of children with Medicaid by race and ethnicity, 2018. Washington, DC: GUCCF.
18 ChildStats. Forum on Child and Family Statistics. HC1 Health Insurance Coverage: Percentage of Children ages 0-17 by Health insurance Coverage at Time of the Interview and Selected Characteristics. 1993-2021.
19 Kusma, J. D., Raphael, J. L., Perrin, J. M., & Hudak, M. L. (2023). Medicaid and the Children’s Health Insurance Program: Optimization to Promote Equity in Child and Young Adult Health. Pediatrics, 152(5), e2023064088.
20 Jeffrey, A. E., & Newacheck, P. W. (2006). Role of insurance for children with special health care needs: a synthesis of the evidence. Pediatrics, 118(4).
21 Committee on Consequences of Uninsurance Institute of Medicine. (2002). Health insurance is a family matter. National Academies Press, Washington DC.
22 Homer, C. J., Klatka, K., Romm, D., Kuhlthau, K., Bloom, S., Newacheck, P., ... & Perrin, J. M. (2008). A review of the evidence for the medical home for children with special health care needs. Pediatrics, 122(4), e922-e937.
23 Perrin, J. M., Romm, D., Bloom, S. R., et al. (2007). A family-centered, community-based system of services for children and youth with special health care needs. Archives of Pediatrics & Adolescent Medicine, 161(10), 933-936.
24 Perrin, J. M. (2008). Prevention and chronic health conditions among children and adolescents. Acad Pediatrics, 8(5), 271.
25 Williams E, Musumeci M. Children with special health care needs: Coverage, affordability, and HCBS access. Kaiser Family Foundation. 2021.
26 Child Welfare Information Gateway. (2022 January). Health-Care Coverage for Children and Youth in Foster Care – and After. Children’s Bureau.
27 Flores, G., Lin, H., et al. (2017). The health and healthcare impact of providing insurance coverage to uninsured children: A prospective observational study. BMC public health, 17(1), 553.
28 Brooks, T., Roygardner, L., Artiga, S., Pham, O., Dolan, R. (2020 March). Medicaid and CHIP Eligibility, Enrollment, and Cost Sharing Policies as of January 2020: Findings from a 50-State Survey - Medicaid/CHIP Eligibility - 9428 | KFF
29 Ercia, A., Le, N., & Wu, R. (2021). Health insurance enrollment strategies during the Affordable Care Act (ACA): a scoping review on what worked and for whom. Archives of Public Health, 79, 1-10.
30 Foster L, Cavanaugh M, Feeley-Summer T. (Fall 2019). How Can My Organization Connect American Indian and Alaska Native Children to Health Coverage? A guide to Fundamentals and Promising Practices. Outreach and Enrollment Fundamentals.
31 Schiff, J., Manning, L., VanLandeghem, K., Langer, C. S., Schutze, M., & Comeau, M. (2022). Financing Care for CYSHCN in the next decade: reducing burden, advancing equity, and transforming systems. Pediatrics, 149(Supplement 7).
32 Guy GP, M Johnston E, Ketsche P, Joski P, Adams EK. The role of public and private insurance expansions and premiums for low-income parents. Medical care. 2017 Mar 1;55(3):236-43.
33 Aller J. Enrolling eligible but uninsured children in Medicaid and the State Children’s Health Insurance Program (SCHIP): A multi-district pilot program in Michigan schools (Doctoral dissertation, Central Michigan University).
34 Harding RL, Hall JD, DeVoe J, Angier H, Gold R, Nelson C, Likumahuwa-Ackman S, Heintzman J, Sumic A, Cohen DJ. Maintaining public health insurance benefits: How primary care clinics help keep low-income patients insured. Patient Experience Journal. 2017; 4(3):61-69.
35 Jenkins J. M. (2018). Healthy and Ready to Learn: Effects of a School-Based Public Health Insurance Outreach Program for Kindergarten-Aged Children. The Journal of school health, 88(1), 44–53.
36 Phillips, M. A., Rivera, M. D., Shoemaker, J. A., & Minyard, K. (2010). Georgia's Utilization Minigrant Program: promoting Medicaid/CHIP outreach. Journal of health care for the poor and underserved, 21(4), 1282–1291.
37 O'Callaghan, M. E., Zgaga, L., et al. (2018). Free Children’s Visits and General Practice Attendance. Annals of Family Medicine, 16(3), 246-249.
38 Fuld J, Farag M, Weinstein J, Gale LB. Enrolling and retaining uninsured and underinsured populations in public health insurance through a service integration model in New York City. American journal of public health. 2013 Feb;103(2):202-5.
39 Flores G, Lin H, Walker C, Lee M, Currie JM, Allgeyer R, Fierro M, Henry M, Portillo A, Massey K. Parent mentors and insuring uninsured children: a randomized controlled trial. Pediatrics. 2016 Apr 1;137(4).
40 Brantley, E. & Ku, L. (2021). Continuous Eligibility for Medicaid Associated With Improved Child Health Outcomes. Medical Care Research and Review, 79(3), 405–413.
41 Routh, J. C., Wolf, S., Tejwani, R., Jiang, R., Pomann, G. M., Goldstein, B. A., Maciejewski, M. L., & Allori, A. C. (2019). Early Impact of the Patient Protection and Affordable Care Act on Delivery of Children’s Surgical Care. Clinical pediatrics, 58(4), 453–460.
42 Arenson, M., Hudson, P. J., Lee, N., & Lai, B. (2019). The Evidence on School-Based Health Centers: A Review. Global pediatric health, 6, 2333794X19828745.
43 Sprecher, E., Conroy, K., Chan, J., Lakin, P. R., & Cox, J. (2018). Utilization of Patient Navigators in an Urban Academic Pediatric Primary Care Practice. Clinical pediatrics, 57(10), 1154–1160.
44 Cousineau, M. R., Stevens, G. D., & Farias, A. (2011). Measuring the impact of outreach and enrollment strategies for public health insurance in California. Health services research, 46(1 Pt 2), 319–335.
45 Williams, S. R., & Rosenbach, M. L. (2007). Evolution of state outreach efforts under SCHIP. Health care financing review, 28(4), 95–107.

This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number U02MC31613, MCH Advanced Education Policy, $3.5 M. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.