Texas saw the largest increase in the rate of uninsured children in the country between 2022 and 2024 — and experts warn it will likely get worse.
Texas once again had the worst rate of uninsured children last year, with more than 13% of kids without coverage. That's more than double the national average and about 5% higher than the next two closest states, Florida and Oklahoma, according to a new analysis from Georgetown University.
What's behind the significant increase in Texas?
Joan Alker, a research professor and executive director of the Georgetown Center for Children and Families, said the way Texas handles Medicaid was part of the reason the state saw a 29% increase in the number of uninsured children between 2022 and 2024.
In 2023, the end of the COVID-19 public health emergency also meant the end of the continuous coverage period for Medicaid. States were tasked with checking the eligibility of everyone in the program.
Nationally, almost 15 million people were disenrolled — about a third of whom were children.
In the process of disenrolling about 1.8 million people, Alker said Texas "barely" used a type of redetermination that helps prevent eligible people from losing coverage. Ex parte, or procedural renewals, involve the state using information and data it has already to determine if someone is still eligible for Medicaid coverage.
"If all states had done as poorly as Texas did with the unwinding, we would have seen a much higher jump in the uninsured rate of children nationally," Alker said.
While the national uninsured rate for children went from about 5% to 6%, Georgetown's analysis of the U.S. Census Bureau's American Community Survey found there was an almost 20% increase in the number of uninsured children nationally. Experts noted that increase is statistically significant.
Concerns about more coverage loss
Lynn Cowles, director of health and food justice at Every Texan, said more children are at risk of losing their coverage due to changes in the federal budget bill, including the more than half a million Texas children enrolled in the federal health insurance marketplace.
"These are the middle-income families, who will really, really get hit by the expiration of the enhanced advanced premium tax credits," Cowles said.
That tax credit is what makes Affordable Care Act, or ACA, coverage more affordable for families. If a child's family makes more than the Medicaid threshold but is still below a certain family income, they can receive the ACA tax credit, or subsidy.
"These are the families that will see hundreds of dollars per month of increases on their marketplace health insurance premiums because the subsidies will reduce," Cowles said.
Nationally, the number of children enrolled in ACA plans has more than doubled since 2020.
Cowles said that loss isn't just limited to the children in the program: The number of Texas adults enrolled in ACA coverage has grown a lot in the past few years — the largest growth in ACA enrollment across all states.
"We saw almost a million, in some cases, over a million more people enroll in ACA plans in Texas. That's just unprecedented," Cowles said. "These are the numbers that we were just like really, really excited about as a community of healthcare advocates."
Now, Cowles and other advocates are concerned those adults are also at risk of becoming uninsured.
Experts warn those risks also extend to other programs, like Medicaid and Medicare, that also saw significant policy changes in the sweeping budget bill signed into law in July.
H.R. 1 is expected to lead to an estimated 480,000 Texans losing coverage, according to KFF Analysis.
What should people do if they're concerned about losing coverage?
Cowles said the easiest and most immediate thing that people can do is to check their mail.
"I know that this is such a bureaucratic thing to say, but like, check your mail," Cowles said. "Be active health care consumers, and when I say be active health care consumers, I mean, re-enroll in your marketplace health insurance plan, log into yourtexasbenefits.com on a regular basis, check the status of your applications."
Cowles said people can put reminders in their phones or calendars to check on their family's coverage.
If anything looks "weird" or incorrect, she said Texans can connect with a local community advocacy organization, like Every Texan or the Texas Organizing Project, to ask questions or get support. If people are comfortable, she said they can even call the Texas Health and Human Services Commission to get support or raise concerns.
"Expect frustration, take notes," Cowles said. "Nobody should have to do this. This should not be regular, right? But the things that people have to do when dealing with giant bureaucracies that effectively set people up to fail – we have to have kind of extra patience, time and capacity to deal with paperwork to keep the programs that that we are eligible for."
Cowles said she recognizes these aren't easy things to add to someone's plate, but they can potentially help people maintain critical health care coverage.
However, Cowles said the list of things can go beyond just checking coverage and taking notes.
"Talk to your friends and neighbors if that feels more applicable to you than it does to call your lawmakers, but either way this is something that we all need to be talking about, especially leading into the midterm elections," Cowles said.
Cowles said this is an issue that affects everyone, not just those most at risk of losing their coverage. She said as the uninsured rate increases, so will dependence on emergency rooms as a primary point of access to health care – which can lead to higher prices for people on private insurance as hospitals work to cover the rising costs of care.
Other potential risks in the future
Joan Alker with Georgetown University and other national experts pointed out there's a substantial lag in how quickly data is released.
"This is data from 2024, and of course, we're in 2025 and the world has changed a great deal," Alker said. "There are many reasons that the situation for children's access to healthcare will substantially worsen, we fear."
One factor Alker said could already be causing an increase is a "chilling effect on mixed status families."
"One out of four children in the United States has an immigrant parent," Alker said. "With the extraordinary fear that's gripping these communities today based on aggressive deportations, as well as the unprecedented sharing of personal Medicaid data by [the Centers for Medicare and Medicaid Services] with ICE, the concerns that parents have about sharing their information with the government right now are very, very real."
Alker said experts saw increases in the uninsured rate tied to these concerns during the first Trump administration.
"We expect the number to grow again, and probably much more quickly," Alker said.
However, the cuts to Medicaid remain the main concern for national experts, including how the loss of adult coverage could impact children.
"As their parents get disenrolled due to onerous red tape, more frequent renewals, work reporting requirements – which will affect parents of older children and may affect parents with younger children if exemptions are not implemented properly or misinformation runs rampant – we know that this means that eligible children will lose coverage, too," Alker said. "Even though they shouldn't."
Alker said the cuts will likely effect provider rates, which could also lead to fewer providers accepting Medicaid coverage.
"The storm clouds are gathering for people who rely on public health insurance and Medicaid," Alker said. "But for children, sadly, they are already here."
Abigail Ruhman is KERA's health reporter. Got a tip? Email Abigail at aruhman@kera.org.
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