QuickTake: Health Insurance Coverage for Children and Parents: Changes between 2013 and 2017


Michael Karpman and Genevieve M. Kenney

September 7, 2017


The health insurance coverage provisions of the Affordable Care Act (ACA) primarily targeted uninsurance among low-income nonelderly adults, including that of parents living with dependent children, which had far exceeded uninsurance among children before the ACA. Several ACA provisions were also expected to affect children’s coverage, and the expansion of coverage for parents was expected to have additional positive spillover effects on coverage for children who were already eligible for Medicaid or the Children’s Health Insurance Program, or CHIP (Aizer and Grogger 2003; Dubay and Kenney 2003; Ku and Broaddus 2000). Indeed, new research finds that Medicaid eligibility for parents was associated with greater coverage gains for children under the ACA (Hudson and Moriya 2017). The Urban Institute’s Health Reform Monitoring Survey (HRMS) is one of several surveys that found coverage gains for parents and children after the implementation of key ACA provisions in 2014 (Alker and Chester 2015; Gates et al. 2016; Karpman, Gates, et al. 2016; Karpman, Kenney, et al. 2016). Whether these improvements in health insurance coverage are sustained will depend on several important decisions facing policymakers this fall, including reauthorization of CHIP, passage of the fiscal year 2018 federal budget, and preparation for the upcoming Marketplace open enrollment period.


In this QuickTake, we provide updated estimates of changes in coverage for children ages 17 and younger and parents ages 18 to 64 who are living with dependent children through March 2017 using data from the HRMS, including supplemental questions focused on children (HRMS-Kids). These estimates highlight the progress made in expanding coverage under the ACA and the risks of repeal and other policies that would reduce federal funding to provide health insurance for families with children. The data and methods used for this analysis are described in an earlier brief (Karpman, Kenney, et al. 2016), though estimates from that brief are not directly comparable to those from the current analysis because of changes in survey weighting procedures. 1


We find a 6.2 percentage point increase in the share of parents with coverage (at the time of the survey) and a 1.9 percentage point increase in the share of children with coverage between June/September 2013 and March 2017 (figure 1). The shares of parents and children who were insured for the full year before the survey increased 6.2 and 2.3 percentage points, respectively. These coverage gains were concentrated in 2014 and early 2015 after implementation of the ACA’s key coverage provisions and, consistent with data from the National Health Interview Survey, appeared to plateau by mid-2015 (Zammitti and Cohen 2017). Despite the larger coverage gains for parents, children remained more likely to have health insurance than parents in March 2017 (table 1).



We find a strong association between the coverage statuses of parents and children. Children with uninsured parents were significantly more likely to be uninsured than children whose parents had coverage. In March 2017, we find a 21.6 percent uninsurance rate among children with uninsured parents and a 0.9 percent uninsurance rate among children with insured parents (figure 2). Patterns in children’s uninsurance by parental coverage status were similar to those found in June/September 2013.



These results highlight the sustained increase in health insurance coverage for parents and children after ACA implementation and the significant linkage between children’s coverage and their parents’ coverage. Additional findings from the March 2017 HRMS show that this increase in coverage among children and parents coincided with improvements in several measures of health care access and affordability (Karpman and Kenney 2017).


Efforts to repeal the ACA and reduce funding for Medicaid and CHIP threaten these recent gains in coverage and access to care for children and parents. For example, the American Health Care Act was projected to reduce coverage by 23 million—including an estimated 3 million children—by 2026 relative to current law, primarily by lowering enrollment in Medicaid and nongroup coverage (Aron-Dine 2017; CBO 2017). The president’s proposed budget for fiscal year 2018 included additional cuts to Medicaid beyond those in the American Health Care Act and would also cut funding for CHIP, which provided health insurance to nearly 9 million children at some point in 2016 (OMB 2017).2 If members of Congress do not reauthorize funding for CHIP by the end of September, states are projected to begin exhausting their federal funding for the program later this year (MACPAC 2017). Access to affordable coverage for parents and children may also be affected by other federal and state policies, particularly with respect to Medicaid. For instance, several states are seeking waivers to impose work requirements on Medicaid beneficiaries, which could reduce coverage for parents and their children.


Given the strong evidence base showing that health insurance coverage improves health care access and affordability and financial well-being, these reductions in coverage would expose many families to significantly higher health care costs and make parents and children more likely to forgo needed care (McMorrow, Gates et al. 2017; McMorrow, Kenney, et al. 2016; Finkelstein et al. 2012; Glied, Ma, and Borja 2017; Howell and Kenney 2012; Hu et al. 2016; Sommers, Blendon, and Orav 2016; Wherry and Miller 2017).


Table 1. Health Insurance Coverage for Parents Ages 18 to 64 and Children Ages 17 and Younger, June/September 2013 through March 2017


June/September 2013

March 2017



Insured at time of survey




Insured all of past 12 months






Insured at time of survey




Insured all of past 12 months




Sample size for parents



Sample size for children



Source: Health Reform Monitoring Survey, quarters 2–3 2013 through quarter 1 2017.
Notes: Estimates are regression-adjusted.
*/**/*** Estimate differs significantly from estimate for June/September 2013 at the 0.10/0.05/0.01 levels, using two-tailed tests.




Aizer, Anna, and Jeffrey Grogger. 2003. “Parental Medicaid Expansions and Health Insurance Coverage.” Working Paper 9907. Cambridge, MA: National Bureau of Economic Research.


Alker, Joan, and Alisa Chester. 2015. Children’s Health Insurance Coverage Rates in 2014: ACA Results in Significant Improvements. Washington, DC: Georgetown University Center for Children and Families.


Aron-Dine, Aviva. 2017. “People of All Ages and Incomes Would Lose Coverage under House Bill, CBO Data Show.” Washington, DC: Center on Budget and Policy Priorities.


CBO (Congressional Budget Office). 2017. Cost Estimate: H.R. 1628, American Health Care Act of 2017. Washington, DC: CBO.


Dubay, Lisa, and Genevieve M. Kenney. 2003. “Expanding Public Health Insurance to Parents: Effects on Children’s Coverage under Medicaid.” Health Services Research 38 (5): 1283–1301.


Finkelstein, Amy, Sarah Taubman, Bill Wright, Mira Bernstein, Jonathan Gruber, Joseph P. Newhouse, Heidi Allen, Katherine Baicker, and the Oregon Health Study Group. 2012. “The Oregon Health Insurance Experiment: Evidence from the First Year.” Quarterly Journal of Economics 127 (3): 1057–1106.


Gates, Jason A., Michael Karpman, Genevieve M. Kenney, and Stacey McMorrow. 2016. “Uninsurance among Children, 1997–2015: Long-Term Trends and Recent Patterns.” Washington, DC: Urban Institute.


Glied, Sherry, Stephanie Ma, and Anaïs A. Borja. 2017. “Effect of the Affordable Care Act on Health Care Access.” New York: Commonwealth Fund.


Howell, Embry M., and Genevieve M. Kenney. 2012. “The Impact of the Medicaid/CHIP Expansions on Children: A Synthesis of the Evidence.” Medical Care Research and Review 69 (4): 372–96.


Hu, Luojia, Robert Kaestner, Bhashkar Mazumder, Sarah Miller, and Ashley Wong. 2016. “The Effect of the Patient Protection and Affordable Care Act Medicaid Expansions on Financial Well-Being.” Working Paper 22170. Cambridge, MA: National Bureau of Economic Research.


Hudson, Julie L., and Asaki S. Moriya. 2017. “Medicaid Expansion for Adults Had Measurable ‘Welcome Mat’ Effects on Their Children” Health Affairs 36 (9): 1643–51.


Karpman, Michael, Jason A. Gates, Genevieve M. Kenney, and Stacey McMorrow. 2016. “Uninsurance among Parents, 1997–2014: Long-Term Trends and Recent Patterns.” Washington, DC: Urban Institute.


Karpman, Michael, and Genevieve M. Kenney. 2017. “QuickTake: Health Care Access and Affordability for Children and Parents: Changes between 2013 and 2017.” Washington, DC: Urban Institute.


Karpman, Michael, Genevieve M. Kenney, Stacey McMorrow, and Jason A. Gates. 2016. “Health Care Coverage, Access, and Affordability for Children and Parents: New Estimates from March 2016.” Washington, DC: Urban Institute.


Ku, Leighton, and Matthew Broaddus. 2000. The Importance of Family-Based Insurance Expansions: New Research Findings about State Health Reforms. Washington, DC: Center on Budget and Policy Priorities.


MACPAC (Medicaid and CHIP Payment and Access Commission). 2017. “Federal CHIP Funding: When Will States Exhaust Allotments?” Washington, DC: MACPAC.


McMorrow, Stacey, Jason A. Gates, Sharon K. Long, and Genevieve M. Kenney. 2017. “Medicaid Expansion Increased Coverage, Improved Affordability, and Reduced Psychological Distress for Low-Income Parents.” Health Affairs 36 (5): 808–18.


McMorrow, Stacey, Genevieve M. Kenney, Sharon K. Long, and Dana E. Goin. 2016. “Medicaid Expansions from 1997 to 2009 Increased Coverage and Improved Access and Mental Health Outcomes for Low-Income Parents.” Health Services Research 51 (4): 1347–67.


OMB (US Office of Management and Budget). 2017. Budget of the United States Government, Fiscal Year 2018. Washington, DC: US Government Printing Office.


Sommers, Benjamin D., Robert J. Blendon, and E. John Orav. 2016. “Changes in Utilization and Health among Low-Income Adults after Medicaid Expansion or Expanded Private Insurance.” JAMA Internal Medicine 176 (10): 1501–09.


Wherry, Laura R., and Sarah Miller. 2017. “Early Coverage, Access, Utilization, and Health Effects Associated with the Affordable Care Act Medicaid Expansions: A Quasi-experimental Study.” Annals of Internal Medicine 164 (12): 795–803.


Zammitti, Emily P., and Robin A. Cohen. 2017. Health Insurance Coverage: Early Release of Quarterly Estimates from the National Health Interview Survey, January 2010–December 2016. Hyattsville, MD: National Center for Health Statistics.



1 In January 2017, we reweighted all rounds of the HRMS from the first quarter of 2013 through the third quarter of 2016 because of a change to the Current Population Survey question on household Internet access that was used to create benchmarks for the original poststratification weights. Under the new procedure, the data are weighted to represent the nonelderly population’s lack of Internet access by age group (18 to 34, 35 to 44, 45 to 54, and 55 to 64 for adult weights; birth to 6, 7 to 12, and 13 to 17 for child weights), based on benchmarks derived from a more stable set of questions on household Internet access from the American Community Survey. Other Current Population Survey and Pew Hispanic Survey questions used in the weighting process are unchanged. The transition to the updated weights has a small effect on national estimates. For instance, in the quarter 1 2016 round of the survey, the unadjusted estimated uninsurance rate is 0.22 percentage points lower for children and 0.03 percentage points lower for parents under the new weights. The effect of reweighting on estimated changes in key outcomes over time is small because the new weighting procedure was applied to all previous rounds of the data. However, because of this change, estimates in this brief are not comparable to estimates in previous HRMS publications. In addition, the HRMS sample size was expanded to approximately 9,500 adults ages 18 to 64 in March 2017, producing a sample size of over 3,000 children in the HRMS-Kids. In previous rounds, the HRMS sample size was about 7,500 adults, with approximately 2,400 children in the HRMS-Kids. ^


2 “Unduplicated Number of Children Ever Enrolled,” Centers for Medicare and Medicaid Services, accessed September 5, 2017; Edwin Park, “Trump Budget Cuts Medicaid Even More than House Health Bill, Showing Dangers of Per Capita Cap,” Off the Charts (blog), Center on Budget and Policy Priorities, May 23, 2017; Joan Alker, “Trump Budget Poses Even More Threats to Children’s Health,” Say Ahhh! (blog), Georgetown University Center for Children and Families, May 23, 2017.^


About the Series


This QuickTake is part of a series drawing on the HRMS, a survey of the nonelderly population that explores the value of cutting-edge Internet-based survey methods to monitor the ACA before data from federal government surveys are available. Funding for the core HRMS is provided by the Robert Wood Johnson Foundation and the Urban Institute. This QuickTake was funded by the David and Lucile Packard Foundation and funding from an anonymous donor. It draws on the HRMS-Kids, which was conducted in partnership with the Center for Children and Families at Georgetown University and is currently funded by the David and Lucile Packard Foundation. The authors are grateful to Stephen Zuckerman for helpful comments on this QuickTake.


For more information on the HRMS and for other QuickTakes in this series, visit www.urban.org/hrms.


About the Authors


Michael Karpman is a research associate and Genevieve M. Kenney is a senior fellow and codirector with the Urban Institute’s Health Policy Center.


Urban Institute Robert Wood Johnson Foundation