Regular readers know that, since record lows in 2016, child uninsurance has been climbing in recent years. Regular readers also know that uninsured rates don’t give a full picture of children’s coverage. Similar to our recent paper on kids who experience coverage gaps, a new article in Pediatrics shows that just having some health insurance coverage isn’t enough to make sure kids have access to affordable care.

Underinsurance Among Children in the United States, Pediatrics

Researchers from the University of Pittsburgh, Harvard University, and the Henry Ford Health System use data from the National Survey of Children’s Health to examine changes in child underinsurance between 2016 and 2019. Underinsurance is defined as having a gap in coverage during the previous year, or having health coverage with benefits that “sometimes” or “never” met their needs, allowed them to see needed providers, or covered or minimized out-of-pocket expenses.

What They Find:

• On average during the 2016-2019 period, nearly 24 million kids (23.7 million, or 32.4%) were underinsured.
• More than 1 in 3 children in 2019 were underinsured (34.0%), an increase of about 2.4 million kids compared to 2016.
• The share of children who reported that their out-of-pocket expenses were only “sometimes” or “never” reasonable increased significantly from 22.2 percent of kids in 2016 to 25.1 percent in 2019, driving the larger increase in underinsurance.
• Although underinsurance increased among kids both with and without special health care needs, kids with more complex health care needs were twice as likely to be underinsured.
• Underinsurance increased more among kids with private coverage, and these kids were 3.5 times more likely than kids with public coverage to report that their insurance benefits did not sufficiently cover their needs.

Why it Matters:

• Public coverage goes a long way towards protecting low- and moderate-income families from underinsurance. As of January 2020, only 4 states charged premiums/enrollment fees for children in Medicaid, and only Tennessee imposed nominal cost-sharing (via waivers). While the number of states with fees and cost-sharing in CHIP is higher, other protections like family out-of-pocket maximums of 5 percent of income help ensure that cost burdens are relatively modest.
• As noted, children with more complex health care needs were also more likely to be underinsured. But a recent analysis by the Kaiser Family Foundation found that more than two-thirds of families who had children with special health care needs covered by Medicaid/CHIP reported that their benefits were always adequate, significantly more than those with private coverage.
• Since the beginning of the pandemic, child enrollment in Medicaid/CHIP has increased substantially, giving millions access to comprehensive coverage with minimal or no cost-sharing. As states begin to prepare for the unwinding of the public health emergency and Medicaid’s related continuous enrollment provision, large shares of children who are still eligible could be disenrolled for procedural reasons. Even if families are able to find other coverage for these children, they could be at serious risk of becoming underinsured.