The number of children under age 19 without health insurance fell to 3.9 million in 2021, according to the U.S. Census Bureau’s annual report on health insurance coverage released today.

That’s 475,000 fewer children without coverage than in 2020.

Health Insurance Coverage in the United States: 2021 shows that children received coverage from a variety of sources. Most children (61.9%) had private coverage primarily through their parents’ plan (Figure 1) but a growing share above the poverty level were covered by public programs.

Many lower-income children qualify for public health assistance programs, such as Medicaid and the Children’s Health Insurance Program (CHIP).

The uninsured rate among children decreased 0.6 percentage points to 5.0% between 2020 and 2021, driven by an increase in public coverage such as Medicaid and CHIP.

Medicaid provides health insurance coverage for children and adults with incomes below a certain income level. CHIP provides health insurance for children in families with income too high to qualify for Medicaid but likely can’t afford private health insurance.

In response to the COVID-19 pandemic, Congress increased funding for Medicaid and passed laws to keep individuals from losing Medicaid coverage during the national health emergency.

In 2021, Congress also introduced measures to increase access to care by reducing the cost of Health Insurance Marketplace coverage (created by the Patient Protection and Affordable Care Act or ACA). In addition, some states adopted measures to make it easier to apply for ACA coverage.

These changes may have contributed to the increase in health coverage of children — even those above the poverty level.

Medicaid and CHIP Drove Drop in Uninsured Rate 2020-2021

The uninsured rate among children decreased 0.6 percentage points to 5.0% between 2020 and 2021, driven by an increase in public coverage such as Medicaid and CHIP. Private coverage rates for children did not change between 2020 and 2021.

In 2021, 35.9% of children were covered by Medicaid or CHIP, up 1.2 percentage points from 2020. Between 2020 and 2021, the number of children covered by Medicaid or CHIP increased by an estimated 752,000.

Figure 1. Health Insurance Coverage Status and Type of Coverage for Children Under 19: 2020 and 2021

Changes in the uninsured rate and in public coverage were not equally distributed across groups, however.

Medicaid and CHIP Coverage Increased for Children Above Poverty

The income-to-poverty ratio provides a measure of family resources. Because Medicaid and CHIP programs are mostly available to families with fewer resources, Medicaid and CHIP coverage rates decline as the income-to-poverty ratio increases. On the other hand, private coverage rates increase as income-to-poverty ratio increases (Figure 2).

But expanded public programs during the pandemic may have contributed to a 0.4 percentage-point drop in the uninsured rate for children in families with incomes at or above 400% of poverty (the poverty threshold in 2021 was about $27,479 for a family with two parents and two kids).

There was no change in private coverage, but coverage through Medicaid and CHIP for this group increased by 1.2 percentage points, and 7.0% of children in this group were covered by Medicaid or CHIP in 2021.

Figure 2. Health Insurance Coverage Rate and Type by Poverty Status of Children Under 19: 2020 and 2021

Although the uninsured rate for children fell overall between 2020 and 2021, there was no change in the uninsured rate for children in families most likely to be eligible for coverage through public programs: those with incomes below poverty or in the middle income-to-poverty category (family income between 100% to 399% of their poverty threshold).

For children in poverty, there was no change in either private coverage or Medicaid and CHIP coverage rates between 2020 and 2021. A 1.9 percentage point increase in Medicaid and CHIP coverage rates offset the 1.5 percentage point drop in private coverage of children in the middle-income category during this period.

Medicaid Expansion and Children’s Health Insurance

Where a child lives may also affect their health insurance coverage.

In 2021, 36 states and the District of Columbia expanded Medicaid eligibility (“expansion states”) under the ACA to extend health coverage to low-income families. The remaining 14 states had not expanded eligibility (“nonexpansion states”) on or before 2021.

In 2021, about 50 million children lived in expansion states, and 27 million in nonexpansion states. About two million (4.0%) children in expansion states and 1.9 million (7.1%) in nonexpansion states did not have health coverage (Figure 3).

The uninsured rate for children living in nonexpansion states decreased by 1.6 percentage points from 2020 to 2021, driven in part by changes in children’s direct purchase coverage in these states.

Direct purchase coverage rates for children in nonexpansion states increased by 1.0 percentage points to 6.0% during this period, including coverage purchased through the Marketplace which increased by 1.2 percentage points to 3.5%.

There was no change in the number or percentage of children covered by Medicaid or CHIP in nonexpansion states.

The uninsured rate of children living in expansion states did not change between 2020 and 2021.

Although Marketplace coverage fell by 0.5 percentage points, Medicaid and CHIP rates rose 1.6 percentage points to 35.5% in expansion states. In 2021, about 691,000 more children in expansion states were covered by Medicaid or CHIP than in 2020.

Figure 3. Health Insurance Coverage and Type by State Medicaid Expansion Status for Children Under 19: 2020 and 2021

Changes in health insurance coverage may result from several factors, including demographic changes in the population, changes in economic conditions, and changes in federal and state policy which impact access to care.

Policies to improve access to care during the COVID-19 pandemic may also have contributed to lower uninsured rates for children, as more children in expansion states received coverage through Medicaid and CHIP, and those in nonexpansion states through the Marketplace during the national emergency.

Laryssa Mykyta is chief of the Census Bureau’s Health and Disability Statistics Branch.

Katherine Keisler-Starkey is an economist and Lisa Bunch is a survey statistician in the Health and Disability Statistics Branch.