As More NC Young Children Become Uninsured, Supreme Court Signals It Is Unlikely to Gut ACA

The Supreme Court indicated during oral arguments yesterday that it is unlikely to throw out the Affordable Care Act (ACA). That is good news during a time when young children’s health uninsurance rates – which have long been declining in North Carolina and nationally – have suddenly ticked up.

Increases in Children’s Uninsurance Rates in Recent Years

Up until 2016, the US – and NC – had been steadily lowering the percent of young children who did not have health insurance, primarily through increasing public health insurance coverage, including through the ACA. Since 2016, however, the percent of uninsured children under age six nationally has risen steadily from 3.8% to 4.7%.

Nineteen states – including NC – showed significant increases in the number or rate of uninsured children under age 6.[1] In fact, during this time period, only one state – Virginia – reduced the number of uninsured young children by a statistically significant amount, likely because of the Medicaid expansion the state enacted. Data show that when newly eligible parents sign up for insurance, they learn their children are eligible and sign them up, too.[2] Therefore, states that expanded Medicaid are tending not to see the big increases in uninsurance rates that non-expansion states (like NC) are seeing (see chart below).

Children (under 18) Uninsurance Rates for States that Expanded Medicaid vs. States that Did Not (2016-2019)[3]


2016 Uninsurance Rate

2019 Uninsurance Rate

Expansion States



Non-Expansion States




Young Children’s Uninsurance Rates in NC

A new state-by-state report from the Center for Children and Families at Georgetown University found that in NC, 142,000 children (under age 18) were uninsured in 2019, an increase of 24% since 2016. This represents a statistically significant increase in the percent of uninsured children.[4]

Young children in NC (those under age 6) have seen even steeper increases in their uninsurance rates than older children. Between 2016 and 2019, the number of young children in NC has increased by 36%, from just under 25,000 to 33,500. The percent of NC young children who are uninsured increased from 3.5% in 2016 to 4.7% in 2019, a statistically significant rate of change. And NC performed poorly compared to the nation as a whole – our state rank in percent of young children uninsured dropped from 25th in 2016 to 32nd in 2019.[5]

Even more concerning: these data about increases in young children’s uninsurance rates in NC were collected before the pandemic hit, during a time of economic growth and low unemployment. 2020 has been a year of job loss and a stalled economy, which have likely increased the uninsurance rates still further.[6]

Georgetown created a data dashboard to go along with its report that is worth exploring. Here’s the NC page. A few highlights:

  • Latinx children in NC have an uninsured rate of 13.3%, more than twice that of all NC chidren 0-18 (5.8%).
  • Children living in families in the range of 138%-250% of the federal poverty level (FPL), which translates to an income range of about $35,500-$64,400 for a family of four, are more likely to be uninsured (8.4%) than their poorer and wealthier peers.
  • The largest sources of insurance for children in NC are employer-sponsored (44%) and Medicaid/State Children’s Health Insurance Plan (SCHIP) (42%).
  • In good news, nearly 95% of Medicaid/SCHIP-eligible children in NC participate in the program – slightly higher than the national average.

The ACA Has Increased Coverage for North Carolinians

A recent Urban Institute report found that about 4.4 million parents living with young children were still uninsured in 2017–18, representing a 40% decline in uninsurance since 2013, following implementation of the major coverage provisions of the ACA. (Of the estimated 4.4 million still uninsured parents living with young children in 2017–18, most were under age 35, about half were Hispanic, and more than half lived in the South.)[7]

Though NC is one of 19 states that has yet to expand Medicaid, the ACA has still benefitted North Carolinians. NC Attorney General Josh Stein and NC DHHS Secretary Mandy Cohen have recently spoken about the benefits of the ACA to NC.

Stein said that more than 500,000 North Carolinians gained health insurance through the ACA, four million North Carolinians with pre-existing conditions are protected from discrimination by the Act, and more than 400,000 working families in the state receive subsidies to help them afford insurance. Cohen urged expansion of Medicaid in NC, which would decrease still further the number of uninsured adults and, as recent data have shown, work to reverse the recent increases in uninsured children as well.[8]

Overturning the ACA would reverse these gains for parents and children alike. The Urban Institute has estimated that if the ACA were overturned by the Supreme Court, 37,000 NC children would stand to lose their health coverage, which would increase the children’s uninsurance rate in the state by 44%. The Urban Institute provided estimates by race as well:[9]


Additional Uninsured Children (0-18)

Percent Increase in Uninsurance Among Children 0-18

American Indian/Alaskan Native



Asian/Pacific Islander



Non-Hispanic Black






Non-Hispanic White




Summary of Court Challenges to ACA to Date

Here’s a quick timeline on challenges to the ACA and how it ended up at the Supreme Court yesterday:

  • In 2012, the Supreme Court heard a case aimed at overthrowing the ACA by claiming that the individual coverage mandate – the requirement that everyone either purchase health insurance coverage or pay a tax – was unconstitutional. Chief Justice John Roberts cast the deciding vote in a 5-4 decision that the mandate was valid under Congress’ power to tax.
  • The Republican-led Congress responded by eliminating the tax penalty, which opened up an opportunity for a group of Republican-led states to sue, arguing that since the individual mandate was no longer tied to a specific tax penalty, it was no longer legal – and since the mandate was intertwined with other provisions, the entire ACA should be deemed unconstitutional. A district court judge in Texas agreed.
  • That decision was appealed by a group of states with Democratic Attorneys General (including NC’s Josh Stein) to the 5th Circuit (Appeals) Court.
  • In December 2019, the appeals court affirmed the decision of the district court that the individual mandate was unconstitutional, but questioned whether the entire ACA had to be thrown out, or whether there was “severability” – meaning, could the individual coverage mandate be removed from the law without bringing down the entire thing?
  • The group of Democratic Attorneys General then appealed the case to the Supreme Court, and those were the oral arguments that were heard yesterday.

A decision on such a high visibility case will likely not be released until the end of the term (June 2021). But Supreme Court experts, including Georgetown University legal scholar Andy Schneider on a conference call yesterday with the Alliance for Early Success, have deduced from the questions asked and comments made by the justices that the Court is likely to decide that there is severability, rather than deeming the entire ACA unconstitutional. Schneider also said that it has been made clear since 2013 that the individual mandate is not essential for the insurance marketplaces to function well.

If you’re a Supreme Court buff and want to read the arguments from yesterday, the Supreme Court website has all the details here.

Health Insurance Coverage Supports Grade-Level Reading

Research shows that both adult and child health insurance rates matter for young child well-being. The Pathways Measures of Success Framework holds up several health insurance indicators as drivers of third grade reading proficiency:

  • Percent of adults with health insurance. Healthy women and men are more likely to conceive healthy babies, and making sure adults have access to health insurance makes for a healthier adult population. Women with health insurance are also more likely to get timely and adequate prenatal care.
  • Percent of parents with health insurance. When parents have health insurance coverage, children are more likely to have insurance, keep insurance, and access needed health care services. Parents with health insurance are healthier and can better support children’s development.
  • Percent of children with health insurance. Children with health insurance are more likely to access primary health care services that can prevent health problems or address existing chronic or acute health conditions. Lack of health insurance can affect a child’s school attendance and ability to participate in school activities.

The ACA, greater outreach, and Medicaid expansion are tools that NC could use to reverse recent trends and improve insurance rates among adults and children, which could in turn help drive improvements in reading proficiency and overall child and family well-being.