Children's Health Insurance Coverage: Progress, Problems, And Priorities For 2021 And Beyond

Does younger children's social health insurance alleviate household impoverishment due to illness?

BACKGROUND

The ambitious expansion of social health insurance in China has played a crucial role in preventing and alleviating poverty caused by illness. However, there is no government-sponsored health insurance program specifically for younger children and inequities are more pronounced in healthcare utilization, medical expenditure, and satisfaction in some households with severely ill children. This study assessed the effectiveness of child health insurance in terms of alleviating poverty caused by illness.

METHODS

Data were collected from two rounds of follow-up surveys using the China Family Panel Studies 2016 and 2018 child questionnaires to investigate the relationship between child health insurance and household medical impoverishment (MI). Impoverishing health expenditure (IHE) and catastrophic health expenditure (CHE) were measured to quantify "poverty due to illness" in terms of absolute and relative poverty, respectively. Propensity score matching with the difference-in-differences (PSM-DID) method, robustness tests, and heterogeneity analysis were conducted to address endogeneity issues.

RESULTS

Social health insurance for children significantly reduced household impoverishment due to illness. Under the shock of illness, the incidences of IHE and CHE were significantly lower in households with insured children. The poverty alleviation mechanism transmitted by children enrolled in social health insurance was primarily driven by hospitalization reimbursements and the proportion of out-of-pocket medical payments among the total medical expenditure for children.

CONCLUSIONS

Children's possession of social health insurance significantly reduced the likelihood of household poverty due to illness. The poverty-reducing effect of social medical insurance is most significant in rural areas, low-income families, no-left-behind children, and infants. Targeted poverty alleviation strategies for marginalized groups and areas would ensure the equity and efficiency of health system reforms, contributing to the goal of universal health insurance coverage in China.

Completion of multidose vaccine series in early childhood: current challenges and opportunities

PURPOSE OF REVIEW

Completion of all doses in multidose vaccine series provides optimal protection against preventable infectious diseases. In this review, we describe clinical and public health implications of multidose vaccine series noncompletion, including current challenges to ensuring children receive all recommended vaccinations. We then highlight actionable steps toward achieving early childhood immunization goals.

RECENT FINDINGS

Although coverage levels are high for most early childhood vaccinations, rates of completion are lower for vaccinations that require multiple doses. Recent research has shown that lower family socioeconomic status, a lack of health insurance coverage, having multiple children in the household, and moving across state lines are associated with children failing to complete multidose vaccine series. These findings provide contextual evidence to support that practical challenges to accessing immunization services are impediments to completion of multidose series. Strategies, including reminder/recall, use of centralized immunization information systems, and clinician prompts, have been shown to increase immunization rates. Re-investing in these effective interventions and modernizing the public health infrastructure can facilitate multidose vaccine series completion.

SUMMARY

Completion of multidose vaccine series is a challenge for immunization service delivery. Increased efforts are needed to address remaining barriers and improve vaccination coverage in the United States.

Racial and Ethnic Disparities in All-Cause and Cause-Specific Mortality Among US Youth

Importance

Mortality rates in US youth have increased in recent years. An understanding of the role of racial and ethnic disparities in these increases is lacking.

Objective

To compare all-cause and cause-specific mortality trends and rates among youth with Hispanic ethnicity and non-Hispanic American Indian or Alaska Native, Asian or Pacific Islander, Black, and White race.

Design, Setting, and Participants

This cross-sectional study conducted temporal analysis (1999-2020) and comparison of aggregate mortality rates (2016-2020) for youth aged 1 to 19 years using US Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research database. Data were analyzed from June 30, 2023, to January 17, 2024.

Main Outcomes and Measures

Pooled, all-cause, and cause-specific mortality rates per 100 000 youth (hereinafter, per 100 000) for leading underlying causes of death were compared. Injuries were classified by mechanism and intent.

Results

Between 1999 and 2020, there were 491 680 deaths among US youth, including 8894 (1.8%) American Indian or Alaska Native, 14 507 (3.0%) Asian or Pacific Islander, 110 154 (22.4%) Black, 89 251 (18.2%) Hispanic, and 267 452 (54.4%) White youth. Between 2016 and 2020, pooled all-cause mortality rates were 48.79 per 100 000 (95% CI, 46.58-51.00) in American Indian or Alaska Native youth, 15.25 per 100 000 (95% CI, 14.75-15.76) in Asian or Pacific Islander youth, 42.33 per 100 000 (95% CI, 41.81-42.86) in Black youth, 21.48 per 100 000 (95% CI, 21.19-21.77) in Hispanic youth, and 24.07 per 100 000 (95% CI, 23.86-24.28) in White youth. All-cause mortality ratios compared with White youth were 2.03 (95% CI, 1.93-2.12) among American Indian or Alaska Native youth, 0.63 (95% CI, 0.61-0.66) among Asian or Pacific Islander youth, 1.76 (95% CI, 1.73-1.79) among Black youth, and 0.89 (95% CI, 0.88-0.91) among Hispanic youth. From 2016 to 2020, the homicide rate in Black youth was 12.81 (95% CI, 12.52-13.10) per 100 000, which was 10.20 (95% CI, 9.75-10.66) times that of White youth. The suicide rate for American Indian or Alaska Native youth was 11.37 (95% CI, 10.30-12.43) per 100 000, which was 2.60 (95% CI, 2.35-2.86) times that of White youth. The firearm mortality rate for Black youth was 12.88 (95% CI, 12.59-13.17) per 100 000, which was 4.14 (95% CI, 4.00-4.28) times that of White youth. American Indian or Alaska Native youth had a firearm mortality rate of 6.67 (95% CI, 5.85-7.49) per 100 000, which was 2.14 (95% CI, 1.88- 2.43) times that of White youth. Black youth had an asthma mortality rate of 1.10 (95% CI, 1.01-1.18) per 100 000, which was 7.80 (95% CI, 6.78-8.99) times that of White youth.

Conclusions and Relevance

In this study, racial and ethnic disparities were observed for almost all leading causes of injury and disease that were associated with recent increases in youth mortality rates. Addressing the increasing disparities affecting American Indian or Alaska Native and Black youth will require efforts to prevent homicide and suicide, especially those events involving firearms.

Associations between Medicaid enrollment and diagnosis stage and survival among pediatric cancer patients

BACKGROUND

Medicaid-associated disparities in childhood and adolescent (pediatric) cancer diagnosis stage and survival have been reported. However, a key limitation of prior studies is the assessment of health insurance at a single time point. To evaluate Medicaid-associated disparities more robustly, we used Surveillance, Epidemiology, and End Results (SEER)-Medicaid linked data to examine diagnosis stage and survival disparities in those (i) Medicaid-enrolled and (ii) with discontinuous and continuous Medicaid enrollment.

METHODS

SEER-Medicaid linked data from 2006 to 2013 were obtained on cases diagnosed from 0 to 19 years. Medicaid enrollment was classified as enrolled versus not enrolled, with further classifications as continuous when enrolled 6 months before through 6 months after diagnosis, and discontinuous when not enrolled continuously for this period. We used multinomial logistic and Cox proportional hazards regression models to determine associations between enrollment measures, diagnosis stage, and cancer death adjusted for covariates.

RESULTS

Among 21,502 cases, a higher odds of distant stage diagnoses were observed in association with Medicaid enrollment (odds ratio [OR] = 1.56, 95% confidence interval [CI]: 1.48-1.65), with the highest odds for discontinuous enrollment (OR = 2.0, 95% CI: 1.86-2.15). Among 30,654 cases, any Medicaid enrollment, continuous enrollment, and discontinuous enrollment were associated with 1.68 (95% CI: 1.35-2.10), 1.66 (95% CI: 1.35-2.05), and 1.89 (95% CI: 1.54-2.33) times higher hazards of cancer death versus no enrollment, respectively.

CONCLUSIONS

Medicaid enrollment, particularly discontinuous enrollment, is associated with a higher  distant stage diagnosis odds and risk of death. This study supports the critical need for consistent health insurance coverage in children and adolescents.

Disparities in Health Insurance Among Middle Eastern and North African American Children in the US

OBJECTIVE

To estimate and compare the proportion of foreign-born Middle Eastern/North African (MENA) children without health insurance, public, or private insurance to foreign- and US-born White and US-born MENA children.

METHODS

Using 2000 to 2018 National Health Interview Survey data (N = 311 961 children) and 2015 to 2019 American Community Survey data (n = 1 892 255 children), we ran multivariable logistic regression to test the association between region of birth among non-Hispanic White children (independent variable) and health insurance coverage types (dependent variables).

RESULTS

In the NHIS and ACS, foreign-born MENA children had higher odds of being uninsured (NHIS OR = 1.50, 95%CI = 1.10-2.05; ACS OR = 2.11, 95%CI = 1.88-2.37) compared to US-born White children. In the ACS, foreign-born MENA children had 2.11 times higher odds (95%CI = 1.83-2.45) of being uninsured compared to US-born MENA children.

CONCLUSION

Our findings have implications for the health status of foreign-born MENA children, who are currently more likely to be uninsured. Strategies such as interventions to increase health insurance enrollment, updating enrollment forms to capture race, ethnicity, and nativity can aid in identifying and monitoring key disparities among MENA children.

Health Insurance Coverage Gaps Among Children With a History of Adversity

Health insurance stability among children with adverse childhood experiences (ACEs) is essential for accessing health care services. This cross-sectional study used an extensive, multi-year, nationally representative database of children aged 0 to 17 to examine the association between ACE scores and continuous or intermittent lack of health insurance over a 12-month period. Secondary outcomes were reported reasons for coverage gaps. Compared with children having 0 ACEs, those with 4+ ACEs had a higher likelihood of being part-year uninsured rather than year-round private insured (relative risk ratio [RRR]: 4.20; 95% CI: 3.25, 5.43), year-round public insured (RRR: 1.37; 95% CI: 1.06, 1.76), or year-round uninsured (RRR: 2.28; 95% confidence interval [CI]: 1.63, 3.21). Among children who experienced part-year or year-round uninsurance, a higher ACE score was associated with a greater likelihood of coverage gap due to difficulties with the application or renewal process. Policy changes to reduce administrative burdens may improve health insurance stability and access to health care among children who endure ACEs.

Consistency and Adequacy of Public and Commercial Health Insurance for US Children, 2016 to 2021

Importance

Before and during the COVID-19 public health emergency (PHE), commercially and publicly insured children may have faced different challenges in obtaining consistent and adequate health insurance.

Objective

To compare overall rates, COVID-19 PHE-related changes, and child and family characteristics associated with inconsistent and inadequate coverage for publicly and commercially insured children.

Design, Settings, and Participants

This was a cross-sectional study using nationally representative data from the 2016 to 2021 National Survey of Children's Health of children from age 0 to 17 years living in noninstitutional settings.

Exposure

Parent- or caregiver-reported current child health insurance type defined as public or commercial.

Main Outcomes and Measures

Inconsistent insurance, defined as having an insurance gap in the past year; and inadequate insurance, defined by failure to meet 3 criteria: (1) benefits usually/always sufficient to meet child's needs; (2) coverage usually/always allows child to access needed health care practitioners; and (3) no or usually/always reasonable annual out-of-pocket payments for child's health care. Survey-weighted logistic regression was used to compare outcomes by insurance type, by year (2020-2021 vs 2016-2019), and by child characteristics within insurance type.

Results

Of this nationally representative sample of 203 691 insured children, 34.5% were publicly insured (mean [SD] age, 8.4 [4.1] years; 47.4% female) and 65.5% were commercially insured (mean [SD] age, 8.7 [5.6]; 49.1% female). Most publicly insured children were either non-Hispanic Black (20.9%) or Hispanic (36.4%); living with 2 married parents (38.4%) or a single parent (33.1%); and had a household income less than 200% of the federal poverty level (79%). Most commercially insured children were non-Hispanic White (62.8%), living with 2 married parents (79.0%); and had a household income of 400% of the federal poverty level or higher (49.1%). Compared with commercially insured children, publicly insured children had higher rates of inconsistent coverage (4.2% vs 1.4%; difference, 2.7 percentage points [pp]; 95% CI, 2.3 to 3.2) and lower rates of inadequate coverage (12.2% vs 33.0%; difference, -20.8 pp; 95% CI, -21.6 to -20.0). Compared with the period from 2016 to 2019, inconsistent insurance decreased by 42% for publicly insured children and inadequate insurance decreased by 6% for commercially insured children during the COVID-19 PHE (2020-2021). The child and family characteristics associated with inadequate and inconsistent insurance varied by insurance type.

Conclusions and Relevance

The findings of this cross-sectional study indicate that insurance gaps are a particular problem for publicly insured children, whereas insurance inadequacy and particularly, out-of-pocket costs are a challenge for commercially insured children. Both challenges improved during the COVID-19 PHE. Improving children's health coverage after the PHE will require policy solutions that target the unique needs of commercially and publicly insured children.

Achieving Child Health Equity: Policy Solutions

Policy solutions to address child health equity, with evidence to support the policies, are presented. Policies address health care, direct financial support to families, nutrition, support for early childhood and brain development, ending family homelessness, making housing and neighborhoods environmentally safe, gun violence prevention, LGBTQ + health equity, and protecting immigrant children and families. Federal, state, and local policies are addressed. Recommendations of the National Academy of Science, Engineering, and Medicine and the American Academy of Pediatrics are highlighted when appropriate.

The Pediatrician Workforce in the United States and China

From 2019 to 2022, the For Our Children project gathered a team of Chinese and American pediatricians to explore the readiness of the pediatric workforce in each country to address pressing child health concerns. The teams compared existing data on child health outcomes, the pediatric workforce, and education and combined qualitative and quantitative comparisons centered on themes of effective health care delivery outlined in the World Health Organization Workforce 2030 Report. This article describes key findings about pediatric workload, career satisfaction, and systems to assure competency. We discuss pediatrician accessibility, including geographic distribution, practice locations, trends in pediatric hospitalizations, and payment mechanisms. Pediatric roles differed in the context of each country's child health systems and varied teams. We identified strengths we could learn from one another, such as the US Medical Home Model with continuity of care and robust numbers of skilled clinicians working alongside pediatricians, as well as China's Maternal Child Health system with broad community accessibility and health workers who provide preventive care.In both countries, notable inequities in child health outcomes, evolving epidemiology, and increasing complexity of care require new approaches to the pediatric workforce and education. Although child health systems in the United States and China have significant differences, in both countries, a way forward is to develop a more inclusive and broad view of the child health team to provide truly integrated care that reaches every child. Training competencies must evolve with changing epidemiology as well as changing health system structures and pediatrician roles.

Medicaid and the Children's Health Insurance Program: an overview for the pediatric radiologist

In terms of number of beneficiaries, Medicaid is the single largest health insurance program in the US. Along with the Children's Health Insurance Program (CHIP), Medicaid covers nearly half of all births and provides health insurance to nearly half of the children in the country. This article provides a broad introduction to Medicaid and CHIP for the pediatric radiologist with a special focus on topics relevant to pediatric imaging and population health. This includes an overview of Medicaid's structure and eligibility criteria and how it differs from Medicare. The paper examines the means-tested programs within the context of pediatric radiology, reviewing pertinent topics such as the rise of Medicaid managed care plans, Medicaid expansion, the effects of Medicaid on child health, and COVID-19. Beyond the basics of benefits coverage, pediatric radiologists should understand how Medicaid and CHIP financing and reimbursement affect the ability of pediatric practices, radiology groups, and hospitals to provide services for children in a sustainable manner. The paper concludes with an analysis of future opportunities for Medicaid and CHIP.

Effects of Medicaid Automatic Enrollment on Disparities in Insurance Coverage and Caregiver Burden for Children with Special Health Care Needs

We analyze how Medicaid automatic enrollment policies for children with special health care needs (CSHCN) who are enrolled in Supplemental Security Income (SSI) reduce disparities in health insurance coverage and caregiving burden. Using the 2009-2010 National Survey of Children with Special Health Care Needs, we implement a difference-in-differences regression model comparing insurance enrollment rates between CSHCN receiving SSI and CSHCN not receiving SSI, in states with and without automatic enrollment policies. We find that Medicaid automatic enrollment has a meaningful impact on insurance enrollment for low-income CSHCN who participate in SSI and can be an effective method for mitigating disparities in insurance coverage (reducing uninsurance by 38%). Medicaid automatic enrollment also reduces caregiver burden among socioeconomically disadvantaged families with CSHCN. The effects of these policies are largest families who might be on the margin of eligibility or who face high administrative burden.

Patterns in Mothers' Recollection of Health Care Providers' Young Child Feeding Recommendations

OBJECTIVE

Characterize feeding guidance mothers recall receiving from their child's health care provider (HCP).

DESIGN

Cross-sectional study of mothers participating in the 2017-2019 National Survey of Family Growth.

PARTICIPANTS

US mothers reporting (n = 1,302) information about their youngest child (aged 6 months to 5 years).

VARIABLES MEASURED

Weighted percentage of mothers who recalled their child's HCP discussing 6 different feeding topics by demographic characteristics.

ANALYSIS

Logistic regression assessing the relationship between recall of feeding guidance and demographics.

RESULTS

In this sample, 36.9% of mothers (95% confidence interval, 32.3-41.4) recalled HCPs recommending solid food before 6 months old (34.6% at 4-5 months, and 2.3% before 4 months). Mothers who were older or had a higher education level were more likely than their counterparts to recall their HCP discussing several of the feeding topics examined.

CONCLUSION AND IMPLICATIONS

Mothers reported high recollection of early childhood nutrition guidance from their HCP; however, certain topics (eg, appropriate timing of solid food introduction) could be prioritized, and some subpopulations may need additional focus to improve receipt of messages. A better understanding of variability in recall of feeding guidance could provide information for interventions to address barriers to receiving and retaining guidance.

Children’s health insurance coverage and adequacy from 2016 to 2018: Racial/ethnic disparities under the ACA

Background:

This study advances health disparities research by documenting the racial/ethnic disparities in children’s health insurance coverage and health insurance adequacy under the implementation and revisions of the Affordable Care Act between 2016 and 2018 in America.

Design and methods:

Combining the nation-wide repeated cross-sectional data from 2016 to 2018 Children’s Health National Survey (NSCH), we examined the changes and trends of health insurance coverage and health insurance adequacy among children age 0–17 across different racial/ethnic groups from 2016 to 2018. Multivariate logistic regression models stratified by race-ethnicity were further analyzed to examine the association between children’s health insurance adequacy, their health insurance coverage, and their socio-demographic background factors.

Results:

Our analyses indicate that generally children’s enrollment in Medicaid or other government aided health care programs had been increasing whereas children’s enrollment in the employer-based had been decreasing from 2016 to 2018. At the same time, the number of children who said that they always had adequate health insurance to meet their health care needs has slightly dropped from 2016 to 2018, except for AIAN children. Our analyses further revealed that the risk of inadequate health insurance appears to be stronger for children in disadvantaged situation, socially and economically.

Conclusions:

The ACA has contributed to expanding childhood health insurance coverage. But racial/ethnic disparities continue to exist in children’s health insurance coverage and health insurance adequacy. To achieve equity in childhood health care, more outreach and appropriate programs are needed for children who are socially and economically disadvantaged.

Upper limb pediatric fractures in 22 tertiary children's hospitals, China: a multicenter epidemiological investigation and economic factor analysis of 32,832 hospitalized children

BACKGROUND

Fractures are the most common type of unintentional injury in children, with traumatic upper limb fractures accounting for approximately 80% of all childhood fractures. Many epidemiological investigations of upper limb fractures in children have been conducted, but with the development of society, the patterns of childhood fractures may have changed. This study aimed to analyze the epidemiology and economic cost factors of upper limb fractures in Chinese children.

METHODS

We retrospectively reviewed children with upper limb fractures or old upper limb fractures hospitalized between December 1, 2015, and December 31, 2019, in 22 tertiary children's hospitals, under China's Futang Research Center of Pediatric Development. We used the ICD10 codes on the front sheet of their medical records to identify cases and extracted data on age, sex, injury cause, fracture site, treatment, the year of admission and discharge, visiting time, and various costs during hospitalization from the medical record.

RESULTS

A total of 32,439 children (21,478 boys and 10,961 girls) were identified, of whom 32,080 had fresh fractures and 359 had old fractures. The peak age was 3-6 years in both sexes. A total of 4788 were infants, 14,320 were preschoolers, 10,499 were in of primary school age, and 2832 were adolescent. Fractures were most frequent in autumn (August to October). Admissions peaked at 0 o'clock. Among the 32,080 children with fresh upper limb fractures, the most common fracture site was the distal humerus, with a total of 20,090 fracture events including 13,134 humeral supracondylar fractures and 4914 lateral humeral condyle fractures. The most common cause of injuries was falling over. The most common joint dislocation accompanying upper limb fractures occurred in the elbow, involving 254 cases. Surgery was performed in 31,274 children, and 806 did not receive surgery. Among those with clear operative records, 10,962 children were treated with open reduction and 18,066 with closed reduction. The number of cases was largest in the East China region (Anhui Province, Shandong Province, Jiangsu Province, Zhejiang Province, and Fujian Province), with 12,065 cases overall. Among the 359 children with old fractures, 118 were admitted with a diagnosis of "old humerus fracture," accounting for the highest proportion; 244 underwent surgical open reduction, 16.16% of whom had osteotomy. For the children with fresh fractures, the average total hospital cost was 10,994 yuan, and the highest average total hospital cost was 14,053 yuan, for humeral shaft fractures. For the children with old fractures, the average total hospital cost was 15,151 yuan, and the highest average total hospital cost was 20,698 yuan, for old ulna fractures. Cost of materials was the principle factor affecting total hospital cost, followed by surgery and anesthesia costs, both in children with fresh fractures and those with old fractures. Significant differences were observed in all hospital costs (P < 0.001) except treatment costs (P = 0.702), between children with fresh fractures and those with old fractures. Among the 32,439 children, full self-payment accounted for the highest proportion of all payment methods, involving 17,088 cases, with an average cost of 11,111 yuan.

CONCLUSION

Information on the epidemiological characteristics of childhood fractures suggests that health and safety education and protective measures should be strengthened to prevent upper limb fractures in children. For both fresh and old fractures, the cost of materials was the principal factor affecting total hospital cost, followed by surgery and anesthesia costs. The overall average total hospital cost is higher in children with old fractures than in children with fresh fractures. Among all children, full self-payment, at 53% of children, accounted for the highest proportion of all payment methods. Hospital costs are a headache for those families who will pay on their own. It can lead to a delayed treatment and unhealed fractures or malunion in some children. Therefore, the child trauma care system and training on fractures need to be improved, to reduce the late presentation of fractures. These combined measures will improve children's quality of life, reduce the expenditure of families, and decrease the public health burden. To provide better medical services for children, authorities must improve the allocation of health resources, establish a comprehensive medical security system for children, and set up more child trauma centers.

Narrowing Insurance Disparities Among Children and Adolescents With Cancer Following the Affordable Care Act

Despite advances toward universal health insurance coverage for children, coverage gaps remain. Using a nationwide sample of pediatric and adolescent cancer patients from the National Cancer Database, we examined effects of the Affordable Care Act (ACA) implementation in 2014 with multinomial logistic regressions to evaluate insurance changes between 2010-2013 (pre-ACA) and 2014-2017 (post-ACA) in patients aged younger than 18 years (n = 63 377). All statistical tests were 2-sided. Following the ACA, the overall percentage of Medicaid and Children's Health Insurance Program-covered patients increased (from 35.1% to 36.9%; adjusted absolute percentage change [APC] = 2.01 percentage points [ppt], 95% confidence interval [CI] = 1.31 to 2.71; P < .001), partly offset by declined percentage of privately insured (from 62.7% to 61.2%; adjusted APC = -1.67 ppt, 95% CI = -2.37 to -0.97; P < .001), leading to a reduction by 15% in uninsured status (from 2.2% to 1.9%; adjusted APC = -0.34 ppt, 95% CI = -0.56 to -0.12 ppt; P = .003). The largest declines in uninsured status were observed among Hispanic patients (by 23%; adjusted APC = -0.95 ppt, 95% CI = -1.67 to -0.23 ppt; P = .009) and patients residing in low-income areas (by 35%; adjusted APC = -1.22 ppt, 95% CI = -2.22 to -0.21 ppt; P = .02). We showed nationwide insurance gains among pediatric and adolescent cancer patients following ACA implementation, with greater gains in racial and ethnic minorities and those living in low-income areas.

Underinsurance Among Children in the United States

OBJECTIVES

We describe the change in the percentage of children lacking continuous and adequate health insurance (underinsurance) from 2016 to 2019. We also examine the relationships between child health complexity and insurance type with underinsurance.

METHODS

Secondary analysis of US children in the National Survey of Children's Health combined 2016-2019 dataset who had continuous and adequate health insurance. We calculated differences in point estimates, with 95% confidence intervals (CIs), to describe changes in our outcomes over the study period. We used multivariable logistic regression adjusted for sociodemographic characteristics and examined relationships between child health complexity and insurance type with underinsurance.

RESULTS

From 2016 to 2019, the proportion of US children experiencing underinsurance rose from 30.6% to 34.0% (+3.4%; 95% CI, +1.9% to +4.9%), an additional 2.4 million children. This trend was driven by rising insurance inadequacy (24.8% to 27.9% [+3.1%; 95% CI, +1.7% to +4.5%]), which was mainly experienced as unreasonable out-of-pocket medical expenses. Although the estimate of children lacking continuous insurance coverage rose from 8.1% to 8.7% (+0.6%), it was not significant at the 95% CI (-0.5% to +1.7%). We observed significant growth in underinsurance among White and multiracial children, children living in households with income ≥200% of the federal poverty limit, and those with private health insurance. Increased child health complexity and private insurance were significantly associated with experiencing underinsurance (adjusted odds ratio, 1.9 and 3.5, respectively).

CONCLUSIONS

Underinsurance is increasing among US children because of rising inadequacy. Reforms to the child health insurance system are necessary to curb this problem.