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

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IMPORTANCE: A rise in pediatric underinsurance during the last decade among households with children with special health care needs (CSHCN) requires a better understanding of which households, by health care burden or income level, have been most impacted. OBJECTIVE: To examine the prevalence of underinsurance across categories of child medical complexity and the variation in underinsurance within these categories across different levels of household income. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study used data from the National Survey of Children’s Health and included 218 621 US children from 2016 to 2021. All children included did not reside in any type of institution (eg, correctional institutions, juvenile facilities, orphanages, long-term care facilities). Data were analyzed from January 2016 to December 2021. EXPOSURES: The primary exposure is a categorization of child health care needs constructed using parent-reported child physical and behavioral health conditions, as well as the presence of functional limitations. MAIN OUTCOMES AND MEASURES: The primary outcome variable is underinsurance, defined as absence of consistent or adequate health insurance. Models were adjusted for demographic and socioeconomic characteristics and stratified by household income. Multivariate logistic regression analysis of pooled cross-sectional survey data across multiple years (2016 to 2021) adjusted for complex survey design (weights). RESULTS: In a total sample of 218 621 children who were not in institutions and were aged 0 to 17 years from 2016 to 2021 (105 478 [48.9%] female; 113 143 [51.1%] male; 13 571 [13.0%] non-Hispanic Black children; 149 706 [51.2%] non-Hispanic White children), underinsurance prevalence was higher among the children who had complex physical conditions (3316 [37.0%]), mental or behavioral conditions (5432 [38.1%]), or complex physical conditions and functional limitations (1407 [40.7%]) or mental or behavioral conditions with limitations (3442 [41.1%]), compared with healthy children (ie, children without special health care needs or limitations) (52 429 [31.2%]). The association between underinsurance and complexity of child health care needs varied by household income. In households earning 200% to 399% federal poverty level (FPL), underinsurance was associated with children having complex physical conditions and limitations (OR, 2.74; 95% CI, 2.13-3.51) and mental or behavioral conditions and limitations (OR, 2.21; 95% CI, 1.87-2.62), compared with healthy children. In households earning 400% or more above FPL, children’s mental or behavioral conditions and limitations were associated with underinsurance (OR, 3.31; 95% CI, 2.82-3.88) compared with healthy children. CONCLUSIONS AND RELEVANCE: In this cross-sectional study, the odds of being underinsured were not uniform among CSHCN. Both medical complexity and daily functional limitations led to increased odds of being underinsured. The concentration of underinsurance among middle-income households underpinned the challenge of health care financing for families of CSHCN whose incomes surpassed eligibility thresholds for dependent Medicaid insurance.


Validova A, Strane D, Matone M, Wang X, Rosenquist R, Luan X, Rubin D