Geographic disparities in levels of health insurance coverage for US children

National and state-level efforts have sought to increase access to health insurance coverage for children. Previous state comparisons of children's health coverage have only examined variations in current insurance status. However, research indicates that both periods without insurance and being underinsured (having insurance that does not sufficiently meet the child's needs) put children at higher risk for adverse outcomes. We used the 2007 National Survey of Children's Health (N=91,642) to measure state-level variation in level of health insurance coverage. We used indicators of insurance adequacy and continuity to create a four-level variable: children who were never insured during the past year; children who had periods without insurance in the last year; children who had continuous but inadequate coverage (the underinsured); and children who had continuous and adequate coverage. We calculated unadjusted and adjusted levels of insurance coverage across states. Wide geographic variations across each level of insurance were found. There was more than a 20-fold difference in the percent of children who were never insured, from 0.4% in Massachusetts to 10.8% in Nevada and over a 3-fold difference in the percent who had periods without insurance, from 5.4% in Massachusetts to 16.9% in Mississippi and a 2-fold difference in the percent who were underinsured, from 14.2% in Hawaii to 27% in Minnesota. Only 55.5% of children in Montana had continuous and adequate coverage compared to 78.6% in Hawaii. State-based patterns of health insurance adequacy can guide national and state efforts to improve access to health insurance coverage for children.