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Researchers at the Harvard School of Public Health estimated that 42 percent of American children will experience at least one gap in health insurance coverage before they turn 18 in a study published on Wednesday.

Over the course of their childhood, about 61 percent of children will be enrolled in either Medicaid or the Children’s Health Insurance Program, according to the study.

The HSPH study is the first to measure cumulative insurance coverage — from both private and public options — throughout the entire duration of childhood. Because existing surveys are only able to measure whether children are insured at specific points in time, it was challenging for researchers to get a comprehensive view of childhood uninsurance.

The study, which was published in the Journal of the American Medical Association, used a microsimulation that mapped out the childhoods of a nationally representative sample of 100,000 simulated children. The researchers used several national datasets, stretching from 2015 to 2019, to predict economic and social changes in each simulated child’s life.

Then, the researchers used data from surveys that collected insurance status to understand how economic characteristics — like insurance history, family income, and state of residence — predict whether a child was likely to be insured at a given point in time.

The results could help researchers understand how children will be affected by Medicaid funding cuts and new limits on coverage eligibility, according to the study’s authors.

“Most of the most recent policies related to Medicaid raised a lot of concerns on children’s health insurance coverage,” said Health Policy Ph.D. candidate Ye Shen, the paper’s first author.

Shen cited two recent policy changes as causes for alarm. In July, the Centers for Medicare and Medicaid Services halted approvals of Section 1115 waivers by states that would have granted continuous eligibility for children under Medicaid and CHIP for multiple years, beyond the 12 months of eligibility required by federal law. Continuous eligibility is designed to allow children to stay insured even if their family income fluctuates.

The same month, President Donald Trump signed a major tax and spending bill, which contains roughly $1 trillion in Medicaid spending cuts and could cut enrollment by 10 million people by 2034, according to projections from the Congressional Budget Office.

“I think potentially, the public is not aware of the size of the affected population, and that’s something that our study is able to offer,” Shen said. “I think there’s a lot of more effort that needs to be put into figuring out what policies can actually help children get covered, as well as to stay covered.”

July’s budget legislation — dubbed the “One Big Beautiful Bill” by congressional Republicans — also limits Medicaid access for noncitizens, ending eligibility for many refugees and asylees.

“These changes could directly affect noncitizen children,” Shen wrote. “Our main findings show that Medicaid and CHIP touch the lives of most American children, suggesting that substantial policy changes may have widespread impact.”

Families without private health insurance have to navigate public options such as Medicaid and CHIP, publicly subsidized credit options like the Affordable Care Act, and employment credit plans alongside more options. These varying options have different types of eligibility criteria and requirements, which can cause disruptions of coverage.

“Studies have documented a lot of these disruptions over short time periods, but those short-term measures can underestimate the size of the affected population,” Shen said. “Our study sought to fill this gap by combining multiple data sources to develop a microsimulation model which projected insurance coverage trajectories from birth to age 18.”

The microsimulation model incorporated multiple periods — each up to three years — of national survey data of children’s insurance and used a “stitching algorithm” to match data samples to each simulated child based on location, demographic, and socioeconomic factors.

“We can’t understand what happens over the course of childhood from simply looking at these short-term measures,” said HSPH associate professor of global health Nicolas A. Menzies, the principal investigator of the lab behind the study. “When you accumulate over the whole course of childhood, we see a much greater incidence of uninsurance and much greater utilization of government supported health insurance.”

The study also found that children living in states that did not expand Medicaid under the Affordable Care Act experienced higher rates of uninsurance. Around 59 percent of children in states that did not expand Medicaid were uninsured at some point, compared to 36 percent in expansion states, the study found.

The researchers say they cannot directly change public policy, but they hope to inform the public of both the sheer size of the population affected by shifts in federal health insurance programs and the extent to which policies can impact children’s lives.

“I don’t think people would think it’s political to be aware of those access-to-care issues and making sure that sick children can seek care,” Menzies said. “What this research points out is just the number of children potentially affected by gaps for care, and hopefully the goals of any political administration are the same in terms of just wanting to make sure that people can get care when they need it, in addition to the other objectives of any health system.”

—Staff writer Andrew Park can be reached at andrew.park@thecrimson.com. Follow him on X @AndrewParkNews.
—Staff writer Nari Shin can be reached at nari.shin@thecrimson.com.