From Progress to Peril: The Rise in Virginia’s Uninsured Rate and the Policy Path Forward

People across Virginia, young and old, strive for good health, and one factor to good health is access to affordable and comprehensive health insurance. In recent years, Virginia made significant progress in connecting people to health coverage, resulting in steep declines in uninsured rates. The combination of expanding Medicaid to more people who need it, temporary enrollment protections for Medicaid during the COVID pandemic, and enhanced premium tax credits that help people afford insurance through the ACA marketplace drove the state’s uninsured rate down to a historic low of 6.4% in 2023. 

Unfortunately, in 2024, Virginia’s overall uninsured rate rose significantly to 6.9%. This means that an estimated additional 52,000 individuals could not access health coverage. Even more concerning, uninsured rates for children (under age 19) rose from 4.6% to 5.2%, which accounts for roughly 11,500 kids not having health coverage.  We know that health coverage, especially at a young age, can have outsized impacts on long-term health outcomes, and a lack of coverage can lead to financial instability for a family in the form of medical debt if an emergency does arise. Fortunately, state lawmakers have options to boost several programs and make sure more people in Virginia stay connected to care.

What Changed from 2023 to 2024

Fewer people were able to access health coverage in 2024 because important protections that were put in place in 2020 ended in April 2023. At the start of the COVID-19 pandemic, the federal government enacted several policies to protect and increase access to comprehensive health coverage. In particular, the 2020 Families First Coronavirus Response Act established a “continuous coverage provision,” which meant that anyone enrolled in health coverage through Medicaid could keep it without needing to undergo an annual review of eligibility. However, when the continuous coverage provision expired on April 1, 2023, Virginia, like all other states, began reviewing and redetermining eligibility for all people enrolled in Medicaid. This process,  commonly referred to as “Medicaid unwinding,” continued through 2023 and 2024 and has resulted in health coverage losses in both years.

TCI, as well as national and state partners, shared our concerns about the impact on people who access health coverage through Medicaid and how this process was set to overwhelm the state eligibility and enrollment system, leading to people getting kicked off coverage due to paperwork and administrative barriers. This appears to be a significant contributing factor to the rise in uninsured rates here in Virginia. Uninsured rates for people who are income-eligible for Medicaid expansion — earning less than 138% of the federal poverty limit or roughly $35,631 for a family of three in 2024– rose significantly from 10.7% to 12.6%.

Taking away Medicaid coverage from adults also harms their children. In addition to the impacts of Medicaid unwinding, the rise in children no longer having health coverage is likely influenced by the “unwelcome mat” effect, where parents may assume their children are no longer eligible for Medicaid when the adults lose coverage, despite children being eligible for health coverage at higher income levels than adults. We also know that thousands of children from low-income families have no access to Medicaid/CHIP or ACA marketplace coverage, regardless of family income, because of limits on eligibility due to immigration status.

What Happens Next for Uninsured Rates

Unfortunately, due to provisions in the recent big federal bill (H.R.1) and the expiration of enhanced premium tax credits, uninsured rates are likely to increase in the coming years. Enhanced ACA premium tax credits (PTCs), which offered more generous subsidies overall and offered subsidies for those earning above 400% of the federal poverty limit (FPL), are set to expire at the end of 2025. While some federal lawmakers are pushing to include funding to continue the enhanced PTCs in their current budget negotiations, failure to do so would lead to an estimated 40,000 people in Virginia becoming uninsured.

An additional 310,000 people are expected to be kicked off health insurance and remain uninsured due to provisions of H.R.1, which includes increased eligibility checks and paperwork requirements for everyone with Medicaid expansion coverage, eliminating access to Medicaid for certain lawfully present immigrants in October 2026, and the introduction of work reporting requirements for some with Medicaid expansion coverage starting in 2027.

Additionally, we may see more mixed-status families, whose members have various immigration statuses, forgo health coverage for their children due to the Trump administration’s recent mass deportation efforts and reports of data sharing between Medicaid and Immigration and Customs Enforcement. This chilling effect may lead to parents with children who are fully eligible for Medicaid/CHIP health coverage forgoing health coverage due to fear of immigration enforcement repercussions.

What Can Lawmakers Do to Mitigate Harm?

While the rise in uninsured rates and the long-term outlook for increased uninsured rates due to federal actions are concerning, Virginia lawmakers have some options to mitigate this harm and improve access and affordability of Medicaid, CHIP, and ACA marketplace coverage.

Medicaid

Virginia lawmakers should strongly consider investing in and revamping their outdated enrollment and eligibility infrastructure, which will be more heavily relied upon once increased redeterminations and work reporting requirements are implemented. Additional funding for training, hiring, and retaining eligibility workers will be critical to ensuring that fewer people are kicked off Medicaid coverage due to unnecessary paperwork and administrative issues, through no fault of their own.

Children’s Health Insurance

Children’s health coverage is essential to setting the youngest in our communities up for success. Increased uninsured rates and future barriers to health coverage — the “unwelcome mat” effect, families being priced out of ACA marketplace coverage, and the chilling effect on mixed-status families — will continue to leave more children without access to health coverage. Virginia’s health coverage programs for children and families, CHIP/FAMIS, can play a critical role in connecting children to care. State lawmakers should consider increasing CHIP/FAMIS income eligibility from 205% FPL ($54,632 for a family of three in 2025) to at least the national median of 255% FPL ($67,958 for a family of three in 2025) as proposed during the 2025 legislative session. Virginia could also consider joining the 19 states and Washington, D.C., that have set CHIP eligibility above 300% FPL. Currently, only Idaho (190% FPL) has a lower CHIP income eligibility limit than Virginia. This change could encourage more parents to consider applying, enroll children who would otherwise go without insurance, and provide more families with financial flexibility to pay for other essentials, such as housing, transportation, and food.

ACA Marketplace

With rising premium costs and less generous help through premium tax credits (PTCs), many families across Virginia will have to weigh continued enrollment in health coverage or prioritizing other essential expenses: a choice no one should have to make. If Congress does not agree to extend enhanced PTCs, state lawmakers should consider targeted state subsidies for those enrolling in the ACA marketplace. Recent analysis estimates that replacing all of the expiring enhanced PTCs would cost the state about $234 million annually. By targeting relief to families with low and moderate incomes (100% FPL to 200% FPL), Virginia could encourage nearly 2 out of 3 households (63%) currently receiving enhanced PTCs to continue coverage at a fraction of the cost to the state ($40.1 million).