Special Article
Underinsurance among Children in the United States
N Engl J Med 2010; 363:841-851August 26, 2010
- Abstract
Background
Recent interest in policy regarding children's health insurance has focused on expanding coverage. Less attention has been devoted to the question of whether insurance sufficiently meets children's needs.
Methods
We estimated underinsurance among U.S. children on the basis of data from the 2007 National Survey of Children's Health (sample size, 91,642 children) regarding parents' or guardians' judgments of whether their children's insurance covered needed services and providers and reasonably covered costs. Data on adequacy were combined with data on continuity of insurance coverage to classify children as never insured during the past year, sometimes insured during the past year, continuously insured but inadequately covered (i.e., underinsured), and continuously insured and adequately covered. We examined the association between this classification and five overall indicators of health care access and quality: delayed or forgone care, difficulty obtaining needed care from a specialist, no preventive care, no developmental screening at a preventive visit, and care not meeting the criteria of a medical home.
Results
We estimated that in 2007, 11 million children were without health insurance for all or part of the year, and 22.7% of children with continuous insurance coverage — 14.1 million children — were underinsured. Older children, Hispanic children, children in fair or poor health, and children with special health care needs were more likely to be underinsured. As compared with children who were continuously and adequately insured, uninsured and underinsured children were more likely to have problems with health care access and quality.
Conclusions
The number of underinsured children exceeded the number of children without insurance for all or part of the year studied. Access to health care and the quality of health care are suboptimal for uninsured and underinsured children. (Funded by the Health Resources and Services Administration.)
Media in This Article
Table 1
U.S. Children Who Were Uninsured, Underinsured, or Fully Insured in 2007, According to Selected Demographic Characteristics.Table 2
Adjusted Odds Ratios for Factors Associated with Underinsurance among Children Who Were Continuously Insured in 2007, According to Type of Inadequacy.Article Activity
- Article
Policy discussions on children's health insurance have been devoted largely to reducing the number of uninsured children.1 As compared with children who have health insurance, those lacking insurance are more likely to have needed care that is delayed or forgone; less access to preventive, specialist, or long-term care; lower utilization rates; care that imposes a high financial burden on their families; and poor health outcomes.2,3 Children with intermittent health insurance (i.e., periods without insurance throughout the year) are at greater risk for delayed care, unmet health care needs, lack of a usual source of care, and nonreceipt of well-child care.4-8
Considerably less attention has been devoted to the problem of underinsurance, or insurance that does not sufficiently meet the child's needs. Recently, the American Academy of Pediatrics issued a policy statement highlighting the importance of this issue.9 The major problems cited were cost-sharing requirements that are too high, benefit limitations, and inadequate coverage of needed services. Although some studies have addressed underinsurance among adults10-12 and others have addressed the adequacy of coverage for children with special health care needs,13-16 more information is needed about the adequacy of health insurance for all children.
We conducted a study that incorporated the multiple dimensions of insurance adequacy cited by the American Academy of Pediatrics: adequate coverage for needed services, an adequate choice of providers, and reasonable coverage of costs. We used information from the 2007 National Survey of Children's Health, a nationally representative study of more than 90,000 children, to address the extent of underinsurance among continuously insured children, the sociodemographic and health factors associated with underinsurance and each of its components, and the association between underinsurance and measures of access and quality.
Methods
Data Collection and Study Design
With funding and direction from the Maternal and Child Health Bureau at the Health Resources and Services Administration, the National Center for Health Statistics (at the Centers for Disease Control and Prevention) conducted the 2007 National Survey of Children's Health using the State and Local Area Integrated Telephone Survey data-collection mechanism. This random-digit-dial survey provides national and state-specific information on the health and well-being of children younger than 18 years of age that is based on interviews with their parents or guardians. Interviews were conducted in English, Spanish, or one of four Asian languages. When households with children were identified, one child from each household was randomly selected to be the subject of the interview. From April 2007 through July 2008, interviews were completed for 91,642 children. The survey was approved by the Research Ethics Review Board at the National Center for Health Statistics. The interview-completion rate (the percentage of completed interviews among known households with children) was 66.0%. Additional details about the survey methods and response rates are available elsewhere.17 All authors contributed to the design and interpretation of the analysis and vouch for the completeness and accuracy of the reported data.
Measurement of Insurance Adequacy
Data on insurance adequacy were based on parents' or guardians' judgments of whether their children's insurance covered needed services and providers and reasonably covered costs. Specifically, adequacy was derived from parents' or guardians' responses to three 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 health care 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 health care?” An affirmative answer to the third question prompted the follow-up question, “How often are these costs reasonable?” A summary measure of adequacy was created by combining the responses to these questions. If a parent or guardian answered “always” or “usually” to all three dimensions of adequacy, then the child was considered to have adequate insurance coverage. (If a parent or guardian reported no out-of-pocket costs, the costs were considered to be “always” reasonable.) If a parent or guardian answered “sometimes” or “never” to any of the three questions, the child was considered to be underinsured. Insurance adequacy was examined only for continuously insured children, defined as those children whose parents or guardians reported that they currently had “any kind of health care coverage, including health insurance, prepaid plans such as HMOs [health maintenance organizations], or government plans such as Medicaid,” and that during the past 12 months, there was not “any time when [the child] was not covered by any health insurance.” Parents or guardians of children without current health care coverage were asked whether, during the past 12 months, there was “any time when [the child] had health care coverage.” These adequacy and health care coverage variables were combined to create a four-level variable: no insurance during the past year, periods without insurance in the past year, continuous but inadequate coverage (underinsurance), and continuous and adequate coverage.
For each level of this variable, we examined the association with five measures of access and quality: delayed or forgone care, difficulty obtaining needed care from specialists, receipt of preventive care, receipt of developmental screening at a preventive visit (for children up to 6 years of age), and care in a medical home. We defined a medical home on the basis of the following five components of the framework established by the American Academy of Pediatrics18: having a personal physician or nurse, having a usual place to receive care when sick, having no problems obtaining needed referrals for care, receiving effective care coordination, if needed, and receiving family-centered, compassionate, and appropriate care. (Family-centered care was assessed with the use of five questions. Care was inferred to be family centered if the parent or guardian reported that the child's doctors usually or always spent enough time with the child, listened carefully to the parent, were sensitive to the family's values and customs, provided needed information, and made the parent feel like a partner.) We also examined each of the components of the medical home separately.
Other variables used in the analyses included the child's age, sex, and race or ethnic group; poverty level; geographic region; family structure; primary household language; household employment status; and child's health status as reported by the parent or guardian, health insurance type, presence or absence of a special health care need, and complexity of special needs.19-23 The presence or absence of a special health care need was determined with the use of a tool developed to screen children for special health care needs, which asks if the child has any of five health consequences (e.g., use of prescription medicine, need for special therapy, and limitations on activity) resulting from a chronic condition.21 Complexity was assessed on the basis of the number of consequences.23
Statistical Analysis
The data analysis consisted of five parts. The first part addressed the distribution of uninsured, underinsured, and fully insured U.S. children according to demographic and health characteristics. The second part used four logistic-regression models to examine factors associated with the overall underinsurance measure and each of its three components among continuously insured children. In these models, underinsured children with continuous coverage were compared with children with continuous and adequate coverage. Maternal level of education and poverty level were not included because of their high correlation with insurance type. The third part examined the association between the measures of access and quality and the four-level insurance variable. The fourth part used adjusted logistic-regression models to examine the association between level of health insurance and the five measures of access and quality plus the five components of a medical home. The fifth part examined the three components of underinsurance in relation to measures of access and quality among continuously insured children. The survey questions used to derive these outcome measures and explanatory variables are available at www.cdc.gov/nchs/slaits/nsch.htm.
Estimates were weighted with the use of survey sampling weights available from the National Center for Health Statistics. These weights reflect the inverse of the probability of being selected for the survey and were adjusted to account for nonresponse and noncoverage of households without landline telephones. Weighted estimates are representative of the U.S. noninstitutionalized population of children. The analyses were conducted using SUDAAN software (version 9.0.1) to account for the complex sample design and to obtain appropriate variance estimates. Unless otherwise specified, a P value of less than 0.05 was considered to indicate statistical significance.
Results
We estimated that 19.3% — or 14.1 million — of all U.S. children (and 22.7% of children with continuous insurance coverage) were underinsured in 2007, exceeding the number of children without any insurance at all during the year (3.4 million) and the number who had insurance during only part of the year (7.6 million). Table 1Table 1
U.S. Children Who Were Uninsured, Underinsured, or Fully Insured in 2007, According to Selected Demographic Characteristics. shows that older children, children in fair or poor health, and children with special health care needs were more likely to be underinsured. Among those with continuous insurance, children with private insurance were more likely to be underinsured (24.2%) than children with public insurance (14.7%).Table 2Table 2
Adjusted Odds Ratios for Factors Associated with Underinsurance among Children Who Were Continuously Insured in 2007, According to Type of Inadequacy. shows that the most common reason for underinsurance was that costs not covered by insurance were considered by respondents to be sometimes or always unreasonable (accounting for 12.1 million children). Smaller proportions of children had health insurance benefits that sometimes or never met the child's needs (3.9 million) or had coverage that sometimes or never allowed them to see needed providers (2.9 million).The adjusted logistic-regression analyses showed that certain groups of continuously insured children were more likely to be underinsured. For children who were 6 to 11 years old and those who were 12 to 17 years old, the odds of being underinsured were 32% and 37% greater, respectively, than for children under 6 years of age. Hispanic and black children were significantly more likely to be underinsured than non-Hispanic white children, and children in the Midwest were more likely to be underinsured than children in the Northeast. Children who were not in very good or excellent health and children with special health care needs had elevated odds of being underinsured. In addition, the odds of being underinsured were twice as high for children with private insurance as for those who had public insurance. The multivariate association of the three components of underinsurance with sociodemographic and health characteristics was highly consistent, except that publicly insured children had lower odds of having adequate coverage for needed providers, whereas privately insured children had more than three times the odds of having inadequate coverage of charges.
As compared with continuously and adequately insured children, underinsured children were significantly more likely to be without a medical home, to have delayed or forgone care, and to have difficulty obtaining needed specialist care (Table 3Table 3
Selected Measures of Access to and Quality of Care According to Insurance Coverage and Adequacy.). With regard to the components of the medical home, underinsured children were less likely to receive needed referrals, care coordination, and family-centered care. Multivariate analyses revealed that children who were underinsured were at increased risk for each of these indicators even after adjustments for sociodemographic and health factors (Table 4Table 4
Adjusted Odds Ratios for Problems with Health Care Access or Quality According to Insurance Coverage and Adequacy.).The strength of the associations between being underinsured and uninsured for all or part of the year was somewhat similar across the measures of access and quality. Using the same multivariate analyses reported in Table 4, we compared the associations between these measures and insurance status (being underinsured, never being insured, and sometimes being insured), with underinsured children as the reference group (see the table in the Supplementary Appendix, available with the full text of this article at NEJM.org). The group of children who were underinsured did not differ significantly from the group of children who were never insured with respect to delayed or forgone care, lack of a medical home, difficulty obtaining referrals, care coordination, family-centered care, or specialist care. The odds of having difficulty obtaining referrals, lacking care coordination, having difficulty obtaining specialist care, and not receiving a developmental screening were similar for children who were underinsured and those who were periodically insured. All other comparisons revealed significant differences between these groups.
Except for lack of developmental screenings, at least one type of inadequacy was significantly associated with each measure of access and quality, after multivariate adjustments (Table 5Table 5
Adjusted Odds Ratios for Problems with Health Care Access or Quality among Continuously Insured Children.). Lack of a medical home, difficulty obtaining referrals, lack of care coordination, lack of family-centered care, delayed or forgone care, and difficulty obtaining specialist care were significantly associated with all three types of inadequacy. Inadequate coverage for needed providers was associated with lack of a usual source of care, lack of a personal doctor, and lack of a preventive visit in the past year. Inadequate benefits or coverage of needed services was associated with lack of a personal doctor.Discussion
Using the 2007 National Survey of Children's Health to measure the adequacy of insurance coverage, we found that almost one quarter of children with continuous insurance were inadequately covered, or underinsured, as indicated by having insurance that did not provide adequate benefits, provider choices, or coverage of costs from the perspective of parents or guardians. This multidimensional approach to defining underinsurance differs from the approaches commonly used in studies of the adult population, which analyze out-of-pocket expenses that exceed certain — often arbitrary — thresholds (e.g., 10% of family income), deductibles that exceed certain levels, gaps in insurance coverage during the year, or benefits that fall below certain benchmarks. These varied approaches have resulted in a wide range of estimates regarding the underinsurance problem. One review of 24 population-based studies showed that the prevalence of underinsurance among adults ranged from 4 to 53%, depending on the definition, sampling frame, data-collection methods, and year the study was conducted. Most reported estimates ranged between 5 and 25%. Only two of the studies we reviewed incorporated more than one dimension of underinsurance in developing their estimates.24
Our estimate of underinsurance is based on multiple measures of the adequacy of insurance: adequate coverage for needed services and providers, and reasonable coverage of costs. Although our approach to estimating underinsurance is more subjective than approaches based solely on measures such as out-of-pocket expenses, it provides a more comprehensive view of insurance adequacy by capturing multiple domains from the family's perspective. Estimates based on out-of-pocket expenses generally consider income level alone, disregarding other financial commitments or variations in assets and debts. By considering families' perspectives on, for example, the reasonableness of out-of-pocket expenses, our approach complements and expands on existing single-domain approaches to measuring underinsurance.
The prevalence of underinsurance varied across groups. Older children, Hispanic children, those residing in the Midwest, and children with either compromised health or special health care needs were more likely to be underinsured. Adolescents may be more likely than younger children to be underinsured because they are more likely to require services that are not well covered by insurance, such as mental health care.25,26 A possible explanation for the higher estimates of underinsurance for children with special health care needs is that such children use the health care system more often than children without such needs and may therefore be disproportionately affected by deductibles, copayments, benefit limitations, and limits on the range of health care providers available for patient care.27 Children with public coverage were much less likely to be underinsured than those with private coverage, perhaps because public insurance programs provide better protection against out-of-pocket expenses.28,29
Our measure of underinsurance permits assessment of the overall prevalence of underinsurance and its underlying components. We found that inadequate coverage of charges was far and away the most common source of underinsurance. We also found that children enrolled in private plans were more than three times as likely as their counterparts in public plans to have inadequate coverage of charges. This dramatic difference is probably the result of federal rules that permit only very limited cost sharing under Medicaid and modest cost sharing under the Children's Health Insurance Program. The latter program provides subsidized insurance for children in families with incomes above eligibility limits for Medicaid but below the level at which families could afford to purchase private insurance on their own. Most states set the upper limit of eligibility for the program at 200 to 300% of the federal poverty level. In 2009, a total of 29 million children were enrolled in Medicaid, and 7 million in the Children's Health Insurance Program.30
We examined the relationship between underinsurance and several measures of access and quality. As compared with fully insured children, those who were underinsured had substantially greater odds of being without a medical home, having difficulty obtaining referrals and care coordination, lacking family-centered care, and having difficulty obtaining needed specialty care. In fact, on the measures of access to referrals, care coordination, and specialty care, the problems affecting underinsured children were similar to those affecting children who had never been insured or who had discontinuous coverage. In contrast, the utilization measures reveal that underinsured children were only slightly less likely than fully insured children to have a usual source of care, to have a personal doctor or nurse, and to have had a preventive medical visit in the past year. Among younger children, those who were underinsured were as likely as fully insured children to have undergone a developmental screening. When we examined the components of underinsurance individually, we found that each of the three types of insurance inadequacy was associated with an increased likelihood of being without a medical home, having care that was delayed or forgone, and having difficulty obtaining referrals.
Our study has several strengths, including a large, nationally representative sample and the comprehensive set of questions on insurance adequacy and access-to-care indicators. However, the study also has limitations. First, the cross-sectional study design makes it difficult to establish the direction of causality. Second, although the data were largely representative of children in the United States, the National Survey of Children's Health excludes children in institutions. Third, the results are subject to biases associated with telephone surveys, including the exclusion of households without landlines (although adjustments were made for both nonresponse and noncoverage). Fourth, there is no single, universally accepted definition of “underinsurance,”31,32 and we could not compare our findings with more objective measures, such as the percentage of family income expended on health care; alternative conceptions of underinsurance might yield different results from those presented here. Finally, we could not examine the health consequences of underinsurance, an important area for future research.
As discussions about the contours of health care reform evolve, 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. Policy discussions often focus exclusively on mechanisms to extend insurance coverage to those with no coverage. 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.
The opinions expressed in this article are those of the authors and do not necessarily reflect the views of the institutions with which the authors are affiliated.
Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.
Source Information
From the Maternal and Child Health Bureau, Health Resources and Services Administration, Department of Health and Human Services, Rockville, MD (M.D.K., R.M.G., G.K.S., B.B.S., P.V.D.), and the National Center for Health Statistics, Centers for Disease Control and Prevention, Hyattsville, MD (S.J.B.); and the Philip R. Lee Institute for Health Policy Studies and the Department of Pediatrics, University of California at San Francisco, San Francisco (P.W.N.).
Address reprint requests to Dr. Kogan at the Maternal and Child Health Bureau, Health Resources and Services Administration, 5600 Fishers Ln., Rm. 18-41, Rockville, MD 20857, or at mkogan@hrsa.gov.
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