Children who are underinsured outnumber uninsured children and are almost as likely as uninsured children to have problems with health care access and quality, according to a study published Aug. 25 in the New England Journal of Medicine.
Nearly a quarter of children with continuous health care coverage in 2007 did not have coverage adequate enough to provide access to appropriate services and providers, according to lead author Michael Kogan, Ph.D., of the Health Resources and Services Administration's Maternal and Child Health Bureau, and his colleagues.
Dr. Kogan and his colleagues analyzed data collected from the 2007 National Survey of Children's Health, which was conducted by random-digital-dial interviews with the parents or guardians of 91,642 children (N. Engl. J. Med. 2010;363:841-51).
They found that in 2007, 19% (14.1 million) of all U.S. children were underinsured (continuous but inadequate coverage), while 5% (3.4 million) were uninsured, and 10% (7.6 million) were sometimes insured. In contrast, 66% (48.2 million) were fully insured.
Children with private insurance were twice as likely to be underinsured as those with public insurance, for example coverage under either Medicaid or a State Children's Health Insurance Program (SCHIP), they wrote. Inadequate coverage of charges was the most common source of underinsurance, accounting for 12.1 million children.
Certain groups of insured children were more likely to be underinsured: those older than 6 years, Hispanic and black children, those in the Midwest, and those who had special health care needs.
Underinsured children had no access to a medical home on the same scale as their sometimes insured peers – 55% and 58% respectively. Dr. Kogan and colleagues found a similar situation regarding access to specialty care: 26% of underinsured children had difficulty obtaining specialist care, compared with 29% of sometimes insured children and 25% of uninsured children.
While attention has been focused on the woes of adult underinsurance, less has been paid to childhood underinsurance, according to Dr. Kogan, who added that it is not clear whether the number of uninsured children has been on the rise over the years, because there are no similar studies for comparison.
As implementation of the Affordable Care Act continues, "it may be worthwhile to consider not only the number of uninsured children in the United States but also the adequacy of coverage for those with current insurance," wrote Dr. Kogan and colleagues.
The study is limited in several ways, the authors wrote. Because the study design was cross-sectional, it is difficult to establish the direction of causality. In addition, the data excludes children in institutions. And, because the study is based on data collected in a phone survey, it is subject to biases, "including the exclusion of household without landlines."
"What I would hope from policymakers is that they would be aware that this problem is more prevalent than the number of uninsured kids and to take that into account in the future policy considerations," Dr. Kogan wrote, noting that HRSA plans on repeating the study within the next few years.
In an accompanying editorial, Dr. James Perrin of the MGH Center for Child and Adolescent Health Policy, Boston, noted that the study offers "compelling evidence that underinsured children face major problems in obtaining both the appropriate quality of care and access to that care. Implementation of the Affordable Care Act offers important opportunities to address the problem of underinsurance" (N. Engl. J. Med. 2010;363:9).
He added, however, that "the Affordable Care Act may leave chronically ill children with CHIP coverage and newly insured Medicaid population underinsured." While expansion of benefits is unlikely, "CHIP and the new Medicaid could offer such benefits to persons meeting certain disability criteria [and potentially offer a better federal match to encourage states to include these benefits]."
Disclosures: The study authors and Dr. Perrin disclosed that they have no relevant conflicts of interest.