A new report from the New England Journal of Medicine indicates that 14.1 million children, or 19.3 percent, were underinsured by their health insurance plans in 2007, and that those with private insurance were more likely to be underinsured (24.2 percent) than children with public health insurance (14.7 percent).
While much attention in public health debate has focused on coverage for those who lack any insurance, these findings show that underinsured children vastly outnumber the uninsured (3.4 million) by a margin of nearly 4-to-1.
The Aug. 25 report, "Underinsurance among Children in the United States," conducted by a number of health institutes, universities and government agencies, was led by Michael D. Hogan, PhD, of the Health Resources and Services Administration's Maternal and Child Health Bureau at the Department of Health and Human Services.
"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," the report's authors said. "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."
"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 authors said.
Using this method, the report showed that particular groups of continuously insured children were more likely to be underinsured. For example, children 6 to 11 years old and those 12 to 17 years old were 32 percent and 37 percent more likely, respectively, to be underinsured than children 6 and younger. In addition, Hispanic and black children were "significantly more likely" to be underinsured than non-Hispanic white children, children in the Midwest were more likely to be underinsured than children in the Northeast, and children in not very good or excellent health or with special healthcare needs had elevated odds of being underinsured.
In a subsequent NEJM editorial, James M. Perrin, a professor or pediatrics at Harvard Medical School and director of the Massachusetts General Center for Child and Adolescent Health Policy, noted that the data used for the study "do not allow comparison of parents' perceptions of reasonableness with measures of actual out-of-pocket costs." He noted that if this "reasonableness of costs" criterion had been excluded, underinsurance rates would have fallen in the 8-percent-to-9-percent range.
"Despite this limitation, the findings of Kogan et al. can help frame key issues at this critical juncture in healthcare reform," wrote Perrin. "An important finding is that children with chronic health conditions have a higher risk of underinsurance than other children. In an earlier study, these authors reported a lower rate of underinsurance among children with special healthcare needs who had public insurance than among those who had private insurance, probably reflecting better coverage of long-term benefits such as specialized therapies in Medicaid, with little or no copayment required."
Of the methodology used, the research notes that "estimates based on out-of-pocket expenses generally consider income level alone, disregarding other financial commitments or variations in assets and debts."
"Our measure of underinsurance permits assessment of the overall prevalence of underinsurance and its underlying components," the report noted. "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."