Underinsured Outnumber Uninsured Kids in the United States

Fran Lowry

August 25, 2010

August 25, 2010 — There are 11 million children in the United States with no health insurance, and an even greater number — more than 14 million — who are underinsured, leaving a huge proportion of kids in the United States with little or no access to good healthcare.

This finding, from a study funded by the Health Resources and Services Administration, is published in the August 26 issue of the New England Journal of Medicine.

"Policy discussions on children's health insurance have been devoted largely to reducing the number of uninsured children," write Michael D. Kogan, PhD, from the Health Resources and Services Administration in the US Department of Health and Human Services, Rockville, Maryland, and colleagues. "Considerably less attention has been devoted to the problem of underinsurance, or insurance that does not sufficiently meet the child's needs."

The authors write that some studies have addressed underinsurance in adults, and others have looked at coverage for children with special healthcare needs. However, more information is needed about the adequacy of health insurance for all children.

To shed more light on this issue, Dr. Kogan and his team used information from the 2007 National Survey of Children's Health, a nationally representative study of 91,642 children, to study the extent of underinsurance among continuously insured children. They also looked at the sociodemographic and health factors associated with underinsurance and the link between underinsurance and measures of access and quality.

The researchers assessed insurance adequacy according to parents' or guardians' judgments of whether their children's insurance covered needed health services and physicians' visits by asking the following questions:

  • Does the child's health insurance offer benefits or cover services that meet his or her needs?

  • Does the child's health insurance allow him or her to see the healthcare providers he or she needs?

  • Not including health insurance premiums or costs that are covered by insurance, do you pay any money for the child's healthcare?

If the answer to the third question was yes, a follow-up question was asked: "How often are these costs reasonable?"

If the response to these questions was "always" or "usually," the child was deemed to have adequate health insurance coverage. If the answers to all the questions were "sometimes" or "never," the child was deemed to be underinsured.

The investigators found that 19.3% (14 million) of all US children, including 22.7% of children with continuous insurance coverage, were underinsured in 2007. This was more than the 3.4 million children without any health insurance and the 7.6 million children who had insurance for part of the year only.

Children older than 6 years, children in fair or poor health, children with special healthcare needs, and Hispanic and black children were significantly more likely to be underinsured than non-Hispanic white children, the authors report.

The study also found that children who had private insurance were more likely to be underinsured than children with public insurance (24.2% vs 14.7%, respectively).

The main reason for categorizing children as underinsured was that costs not covered by insurance were considered to be sometimes or always unreasonable by the parents or guardians. Some children — 3.9 million — had health insurance that did not meet their needs, and 2.9 million children had coverage that sometimes or never allowed them to see needed providers, the authors found.

Although the study has several strengths, including a large, nationally representative sample of children, it also has limitations, the authors note. The study's cross-sectional design makes it difficult to determine direction of causality for underinsurance; in addition, children living in institutions were excluded, there is no universally accepted definition of underinsured, and surveys were done over the telephone, which is subject to bias and also excluded families without landlines. Finally, the authors note, their study was not designed to examine the health consequences of underinsurance — they suggest this be a topic for future research.

The authors also suggest that, as healthcare reform evolves, it may be worthwhile to consider the adequacy of coverage for children with current insurance, and not just to focus on the number of uninsured children.

"This study shows that underinsured children have problems with access to health care that are similar to those of uninsured children and that underinsurance among children is actually more prevalent than lack of insurance," they conclude.

In an accompanying editorial, James M. Perrin, MD, from the Massachusetts General Hospital for Children, Boston, writes that these findings can help frame key issues at this critical juncture in healthcare reform.

"Kogan et al offer compelling evidence that underinsured children face major problems in obtaining both the appropriate quality of care and access to that care," Dr. Perrin writes. "Implementation of the Affordable Care Act offers important opportunities to address the problem of underinsurance."

This study was funded by the Health Resources and Services Administration. One study author reports employment by University of California, where payment was received from the Federal Maternal and Child Health Bureau, US Department of Health and Human Services. The other authors and Dr. Perrin, the editorialist, have disclosed no relevant financial relationships.

N Engl J Med. 2010;363:841-851, 881-883.