For the first Dragon Tree Blog post, we're looking at numbers, numbers, numbers. Here at Dragon Tree, we're interested in helping organizations help people thrive. And there's no one more in need of support these days than children.

So over a two-part blog series, we'll be diving into insurance enrollment numbers for children. The reason behind why we find this kind of exploration interesting requires a quick history lesson as to the evolution of government-sponsored health insurance over the past two years (it'll be quick, we promise!).

According to a recent report by the Assistant Secretary for Planning and Evaluation in the U.S. Department of Health and Human Services, "In Q1 2024, 42.4 percent of children had public coverage and 54.2 percent had private coverage."

Also of note, between "Q2 2023 and Q1 2024…(t)he percentage of children with public coverage declined by 2.7 percentage points…"

A clarification: by "public coverage," the report is referring to government-sponsored healthcare insurance. This type of insurance takes the form of Medicare and, in the case of children and other special cases, Medicaid.

Medicaid is administered by states on behalf of a federal agency called the Centers for Medicare & Medicaid Services, and each state has different criteria by which children qualify for it. In general, families have to earn a certain amount of income in relation to the federal poverty level to qualify.

Against this backdrop of declining public insurance coverage in the U.S., several states have begun widening eligibility criteria for government-sponsored healthcare insurance, particularly when it comes to children. During the Covid health emergency, which lasted from the early days of the pandemic until the spring of 2023, Medicaid enrollees — including children — couldn't be "dis-enrolled" from their coverage due to life events.

The federal Covid emergency lasted for about three years. When it officially ended in 2023, a process called "Medicaid unwinding" took place where people were once again eligible to lose their Medicaid coverage based on changes in their life circumstances.

To soften the blow that the unwinding occasioned, several states agreed to expand Medicaid eligibility to include more children. The process of opening up access often proves relatively long and involved given that states have to pass legislation to enact it; for this reason, only in recent months have these plans been implemented.

This brings us to the task at hand.

To help us gain insight into how expanded enrollment is going, we'll highlight enrollment numbers in four states: in blog post #1 we'll focus on Arizona and Maine, and in blog post #2, we'll hone in on North Dakota and Kansas.

We've chosen these states because they represent the entire political spectrum: one of these states is reliably liberal (Maine), one is a swing state (Arizona), and two are reliably conservative states (North Dakota and Kansas). This should give us a good sense of the varieties of expansion on offer as they relate to children, and to what degree they're proving successful.

In this post, we'll confine our inquiries to enrollment in the Children's Health Insurance Program (CHIP). CHIP is an adjunct to Medicaid that provides "low-cost health coverage to children in families that earn too much money to qualify for Medicaid." Several states focused on expanding access to this program as the continuous enrollment condition authorized by the Families First Coronavirus Response Act (FFCRA) came to a close in the spring of 2023.

In all of these states (with the exception of Kansas), the expansions have only recently taken effect. Kansas is a special case, since expanding CHIP eligibility to cover more children has been the subject of debate there for some time now, but hasn't yet passed. Because of this, I thought it would be interesting to compare Kansas' current Medicaid child enrollment numbers to those of states where CHIP expansion has taken place.

We'll take a look at numbers available at data.medicaid.gov to review the first few months of data rolling in. This data set collected by Medicaid is lagging by about four months, so the latest update on October 31st only measures enrollee numbers through July of 2024.

While this is a very small window of time that will yield little in the way of patterns from which we can draw any sort of conclusions, it will at least give us an idea of preliminary numbers. We plan to continue watching how these numbers move over time.

Let's start with Arizona.

As part of the state budget approval process in 2023, Governor Katie Hobbs and the state legislature agreed on an expansion of KidsCare, which is the name of Arizona's CHIP program. The decision, which enjoyed bipartisan support, allowed KidsCare to expand eligibility to cover more children by increasing family income limits.

According to the KidsCare website, "To qualify for KidsCare, annual family income limits are rising to 225% of the federal poverty level, or an annual household income of up to $70,200 for a family of four."

Since the expansion took effect on March 1, 2024, we thought it would be interesting to look at the first few months of data.

Up first is a graph tracking enrollment rates between May and July of 2024.

Data courtesy of data.medicaid.gov

Curiously, unlike other states on the list, there isn't much data for CHIP enrollment numbers in Arizona prior to May of 2024. As stated above, since access expansion only began in March of this year in Arizona, there isn't much data available. As a consequence, this graph can't tell us much of anything aside from the fact that CHIP enrollment numbers have fallen slightly since families started enrolling their children under the expansion. Again, we'll keep an eye on these numbers to see what happens over time.

Now on to Maine. It's important to note that while the CHIP expansion has already been approved, it didn't take effect until August of 2024; consequently, since our data source only has updated numbers through July of 2024, we won't see the expansion reflected in the figures just yet.

But that's OK! We can at least visualize the starting point, and then see if it moves over time.

For now, let's familiarize ourselves with the particulars of Maine's expansion. According to the State of Maine Health and Human Services website, the following is true relative to the eligibility standards for children under the age of 21 in Maine's CHIP program:

"Part 5, Section 6, Income Standard increases the household income for all children from 208% of the Federal Poverty Level (FPL) to 300% of the FPL effective retroactive to October 1, 2023."

So a few things are going on here that are different from Arizona, namely that household income requirements are a bit more generous (300% of the Federal Poverty Level in Maine, compared to 225% in Arizona), and enrollment is retroactive to an earlier date than Arizona's eligibility date.

That being the case, here is a chart looking at CHIP enrollment rates going back a bit further in time, to January of 2023:

Data courtesy of data.medicaid.gov

We expanded our time frame here because we think it's important to show that CHIP enrollment has been relatively consistent in Maine over the past couple of years, with the exception of a dip in the summer and fall of 2023. This will provide important context as we watch these rates over time.