Millions of US Children Have Inadequate Health Care Coverage

Inadequate health coverage is a particular problem for commercially insured children, according to a new study released by the Columbia University Mailman School of Public Health. Research shows that coverage gaps also affect publicly insured children. To date, prior research has focused on documenting insurance consistency rates and trends for children covered by all types of insurance. The findings were published in JAMA Health Forum.

Although overall child uninsurance is declining in the US, our results highlight the need for a renewed focus on ensuring that children’s coverage is affordable for families and provides the benefits needed of children, says Jamie Daw, PhD, assistant professor of health policy and management at the Columbia Mailman School of Public Health.

Using representative data from the 2016-2021 National Survey of Children’s Health, researchers analyzed parent or guardian-reported health insurance data for children age 17 and also compared changes over time. of COVID-19, identifying inconsistent and inadequate coverage within each insurance type.

Inadequate insurance is defined by failure to meet three criteria: benefits are sufficient to meet a child’s needs; coverage allows a child to see necessary health care providers; and lack of reasonable annual out-of-pocket payments for children’s health care.

Inconsistency in coverage was three times higher among public compared to commercially insured children. However, underinsurance is more prevalent overall, affecting nearly one in five US children (16.5 million annually), with particularly high rates among the commercially insured. The researchers also found that child and family characteristics associated with higher rates of inconsistent and inadequate coverage differed by type of insurance.

In the sample of 203,691 insured children, 34.5 percent are publicly insured and 65.5 percent are commercially insured. Compared to commercially insured children, publicly insured children had higher rates of unequal coverage (4.2 vs. 1.4%,) and lower rates of inadequate coverage (12 vs. 33% ). Relative to 2016-19, inadequate insurance decreased by 42 percent for publicly insured children and inadequate insurance decreased by 6 percent, for commercially insured children during the COVID period.

In summary, the findings indicate:

One in five children in the US has inadequate health insurance, meaning insurance that either has unreasonable out-of-pocket costs or does not have benefits that meet children’s medical needs.

Inadequate coverage is particularly high among children with commercial insurance (about 1 in 3 commercially insured compared to 1 in 10 publicly insured children).

Insurance gaps (ie, periods without coverage) are more common for publicly insured children.

Both commercial insurance eligibility and public insurance gaps have been reduced significantly during the COVID-19 pandemic when there are additional subsidies for commercial insurance and requirements for states to keep beneficiaries enrolled in Medicaid.

With protections ending in 2023 following COVID, many publicly insured children are losing coverage that would reverse the gains in uniform coverage seen during the pandemic.

More needs to be done to protect commercially insured families against high out-of-pocket costs for child health care and ensure benefits/provider networks are adequate to meet children’s needs.

Also, Daw and colleagues note that there is a particular need for state Medicaid programs to conduct targeted outreach and language- and culturally competent navigation assistance for immigrant families.

Federal COVID-19 aid policies prevented states from disenrolling children from Medicaid and implemented enhanced subsidies for private Marketplace coverage. Our study findings suggest that these policies made an important difference for families during the pandemic: publicly insured children had fewer gaps in coverage and coverage was more affordable. so for commercially insured children. Policymakers must actively consider how to maintain and build on these advantages, Daw said.

Co-authors are Sarra Yekta, Columbia Mailman School of Public Health; Faelan Jacobson-Davies and Lindsay Admon University of Michigan; and Stephen Patrick, Vanderbilt University Medical Center

The study was funded by the Agency for Healthcare Research and Quality (R01HS029159).

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