Underinsurance among children in the United States and its association with health care access and quality

While national attention has focused on expanding health insurance coverage to children who are uninsured, less attention has been given to the issue of underinsurance or inadequate insurance. Underinsurance has been studied among children with special health care needs (CSHCN). However, no study has examined underinsurance among all US children. We used the 2007 National Survey of Children's Health, a nationally representative study of over 90,000 children to address this issue. Children with health insurance were considered underinsured if a parent reported that the benefits did not usually or always meet the child's needs; or costs not covered by insurance were not usually or always reasonable; or the insurance plan did not usually or always allow the child to see needed providers. Using bivariate and multivariate analyses, we examined the association between underinsurance and measures of health care access and quality by creating a 4-level variable: uninsured for the past year; uninsured part of the year; continuous but underinsured coverage; and continuous and adequately insured. We found that about 20% of US children were underinsured. Compared to children who were continuously insured with adequate coverage, children who were underinsured were significantly more likely to have delayed or forgone care; have problems receiving referrals; have problems with care coordination; have problems obtaining specialist care; and to not have a medical home. These findings suggest that a high percentage of US children, although considered insured, are underinsured, and that these children are at increased risk for health care access and quality problems.