Underinsurance Among Children With Special Health Care Needs in the United States

Key Points Question Is medical complexity of child physical or behavioral health care needs associated with the risk of underinsurance among children across different household income levels? Findings In this cross-sectional study of 218 621 US children from 2016 to 2021, the prevalence of underinsurance was higher among children with complex physical and/or behavioral health care needs compared with healthy children (ie, children without special health care needs). For most child health care needs categories, underinsurance was highest among families with incomes between 200% and 399% of federal poverty level. Meaning These findings suggest that chronic medical or behavioral health issues in children who have functional limitations compound the odds of being underinsured, particularly for children from middle-income households.


Notes:
1) Chronic health conditions are defined as lasting 12 months or more.
2) Each survey question was followed by additional questions that specified if the child needed the prescribed medication/more medical care than others/special therapy/treatment for emotional/behavioral problem or had limited ability because of any medical, behavioral, or other health condition that lasted or is expected to last 12 months or longer.A positive answer means answering "yes" to all the questions including clarifying questions.3) To be categorized as a child with complex physical health conditions but no limitations the respondent had to answer positively to Q2 or Q3. 4) To be categorized as a child with complex physical health conditions and limitations the respondent had to answer positively to Q2 or Q3, and Q5.

Control Variables
We included the following demographic control variables: age, sex, race/ethnicity and child immigrant status.Age was a categorical variable and included three age groups: 0-5, 6-11 and 12-17-year-old children.Race/ethnicity variable distinguished between four categories: Non-Hispanic Whites (reference category), Non-Hispanic Blacks, Hispanics, and Other racial/ethnic group.The questions about child's Hispanic origin and race were asked in the initial screening questionnaire.Non-Hispanic children reporting one race category of Asian, American Indian or Alaska Native, Native Hawaiian or other Pacific Islander, and multi-race were grouped as other.Following NSCH classification of child's immigrant status, we distinguished between 1 st generation household (child is born outside of the United States), 2 nd generation household (child is born in the United States and at least one parent is born outside the U.S.), 3 rd + generation household (both parents are born in the U.S.) and other (child is born in the U.S., parents are not listed).
The following socio-economic variables were included in the analysis: parental educational attainment, household income, and type of health insurance coverage.Highest parental education was categorized as "less than high school", "high school", "some college or associate degree", and "college degree or higher".Household income variable (measured as a percentage of the federal poverty level (FPL)) was derived by NSCH from responses on the survey about household income and was generated using single imputation method.Four categories were created: 0-99% FPL (reference category), 100-199% FPL, 200-399% FPL, and 400% FPL or above.Finally, previously shown to significantly predict underinsurance (Yu et al, 2022), type of health insurance coverage was included in our models.Insurance type was categorized as follows: (a) only public health insurance, defined as Medicaid, Medical Assistance, or any kind of government assistance plan with those with low income or a disability, (b) only private insurance, (c) combined public and private health insurance, and (d) no current insurance coverage.2) 1 Model 1 is unadjusted model 2 Model 2 has been adjusted for demographic and socioeconomic variables 3 Model 3 is an adjusted model which includes interaction between child healthcare needs and household income level 3) 4 "Other" racial/ethnic category included Non-Hispanic children reporting one race category of Asian, American Indian or Alaska Native, Native Hawaiian or other Pacific Islander, and children who reported more than one race.

eTable 2 .
Characteristics of Children in the United States, by Children's Healthcare Needs Category, National Survey of Children's Health (NSCH) (2016 to 2021)

Risk ratios* for underinsurance among children in the United States, NSCH 2016-2021
Underinsurance is defined as failure to meet either of the following: 1) continuous insurance in the past 12 months, and 2) current insurance that is adequate for the child's healthcare needs.Health insurance is defined as adequate if: (a) benefits meet child's needs, and (b) insurance allows the child to see needed providers, and (c) the insurance either has no out-of-pocket expenses or out-of-pocket expenses are reasonable.3) 1 "Other" racial/ethnic category included Non-Hispanic children reporting one race category of Asian, American Indian or Alaska Native, Native Hawaiian or other Pacific Islander, and children who reported more than one race.
eTable 3. © 2023 Validova A et al.JAMA Network Open.Notes: 1) * Modified Poisson regression was used to generate RR and CI