Underinsurance Among Children in the United States

Supporting the Well-Being of Children and Youth With Special Health Care Needs: NASEM Proceedings

Children and youth with special health care needs (CYSHCN) are living longer than ever. These advances come with a price: Patients, families, communities, and systems must absorb the challenges of chronic caregiving, including protracted stress and poor mental health. In 2023, the National Academies of Science, Engineering, and Medicine convened thought-leaders for conversations about supporting the emotional well-being of CYSHCN and their families. Invited panelists included 2 parents and 3 academic pediatricians. Parents suggested opportunities for clinicians and systems to better support CYSHCN. Clinicians described work focused on: Individual patient- and family-level resilience: Defined as a process of harnessing resources to sustain well-being in the face of stress, resilience is learnable. Programs that teach people to identify and bolster "resilience resources" show promise in improving child and caregiver mental health;Clinician- and practice-level provision of care: Individual-level interventions are only effective if clinicians know when and how to deliver them. Hence, the American Board of Pediatrics created and demonstrated the success of a "roadmap" to support routine screening for and discussion of social and emotional health needs; andSystems-level barriers: Even with patient-level programs and clinician-practice guidance, unmet social and mental health needs persist. Accessing and coordinating services is difficult, may not be covered by insurance, and historically marginalized populations are the least likely to benefit. Together, the panel underscored a critical fact: We cannot optimize child and family well-being without focusing on patients, caregivers, clinicians, and systems.

Self-Reported Well-Being of Family Caregivers of Children with Medical Complexity

OBJECTIVE

Provide an in-depth and psychometrically rigorous profile of the emotional well-being and sleep-related health of family caregivers of children with medical complexity (CMC).

METHODS

Cross-sectional survey study of family caregivers of CMC receiving care from a pediatric complex care center between May 2021 and March 2022. Patient Reported Outcomes Measurement Information System Short-Forms (PROMIS-SF) assessed global mental health, emotional distress (anxiety, depression, anger), psychological strengths (self-efficacy, emotional regulation, meaning and purpose), and sleep-related health (fatigue, sleep-related impairment). Student's t-tests compared the sample's mean T-scores to US population norms. Pearson's correlation coefficient (ρ) examined associations between measures of psychological strengths and emotional distress. Unadjusted linear regression analyses explored relationships between well-being outcomes and child and caregiver characteristics.

RESULTS

Compared to US population norms, caregivers of CMC (n = 143) reported significantly lower global mental health and emotional regulation ability as well as elevated symptoms of anxiety, depression, anger, fatigue, and sleep-related impairment (all P < .01). Whereas participants reported a significantly higher sense of meaning and purpose (P < .05), levels of self-efficacy were not significantly different from population norms. We observed moderate-to-strong inverse relationships between psychological strengths and emotional distress (ρ range, -0.39 to -0.69); with the strongest inverse associations found between emotional regulation ability and emotional distress. In exploratory analyses, caregiver race and ethnicity, socioeconomic status, and child health insurance type were significantly associated with caregiver well-being.

CONCLUSION

Family caregivers of CMC report poor well-being, most notably, increased symptoms of anxiety and reduced global mental health and sleep-related health.

Incidence of pediatric narcolepsy diagnosis and management: evidence from claims data

STUDY OBJECTIVES

The purpose of this study was to characterize the incidence of pediatric narcolepsy diagnosis, subsequent care, and potential sociodemographic disparities in a large US claims database.

METHODS

Merative MarketScan insurance claims (n = 12,394,902) were used to identify youth (6-17 years of age) newly diagnosed with narcolepsy (International Classification of Diseases, 10th revision codes). Narcolepsy diagnosis and care 1 year postdiagnosis included polysomnography with Multiple Sleep Latency Test, pharmacological care, and clinical visits. Potential disparities were examined by insurance coverage and child race and ethnicity (Medicaid-insured only).

RESULTS

The incidence of narcolepsy diagnosis was 10:100,000, primarily type 2 (69.9%). Most diagnoses occurred in adolescents with no sex differences, but higher rates in Black vs White youth with Medicaid. Two thirds had a prior sleep disorder diagnosis and 21-36% had other co-occurring diagnoses. Only half (46.6%) had polysomnography with Multiple Sleep Latency Test (± 1 year postdiagnosis). Specialty care (18.9% pulmonary, 26.9% neurology) and behavioral health visits were rare (34.4%), although half were prescribed stimulant medications (51.0%). Medicaid-insured were 86% less likely than commercially insured youth to have any clinical care and 33% less likely to have polysomnography with Multiple Sleep Latency Test.

CONCLUSIONS

Narcolepsy diagnoses occurred in 0.01% of youth, primarily during adolescence, and at higher rates for Black vs White children with Medicaid. Only half overall had evidence of a diagnostically required polysomnography with Multiple Sleep Latency Test, underscoring potential misdiagnosis. Many patients had co-occurring conditions, but specialty and behavioral health care were limited. Results suggest misdiagnosis, underdiagnosis, and limited narcolepsy treatment, as well as possible disparities. Results highlight the need to identify determinants of evidence-based pediatric narcolepsy diagnosis and management.

CITATION

Tang SH, Min J, Zhang X, et al. Incidence of pediatric narcolepsy diagnosis and management: evidence from claims data. J Clin Sleep Med. 2024;20(7):1141-1151.

Pediatric Population Management Classification for Children with Medical Complexity

Improving the overall care of children with medical complexity (CMC) is often beset by challenges in proactively identifying the population most in need of clinical management and quality improvement. The objective of the current study was to create a system to better capture longitudinal risk for sustained and elevated utilization across time using real-time electronic health record (EHR) data. A new Pediatric Population Management Classification (PPMC), drawn from visit diagnoses and continuity problem lists within the EHR of a tristate health system, was compared with an existing complex chronic conditions (CCC) system for agreement (with weighted κ) on identifying CCMC, as well as persistence of elevated charges and utilization from 2016 to 2019. Agreement of assignment PPMC was lower among primary care provider (PCP) populations than among other children traversing the health system for specialty or hospital services only (weighted κ 62% for PCP vs. 82% for non-PCP). The PPMC classification scheme, displaying greater precision in identifying CMC with persistently high utilization and charges for those who receive primary care within a large integrated health network, may offer a more pragmatic approach to selecting children with CMC for longitudinal care management.

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.

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

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.

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.

Principles of Child Health Care Financing

The American Academy of Pediatrics believes that the United States can and should ensure that all children, adolescents, and young adults from birth through the age of 26 years who reside within its borders have affordable access to high-quality comprehensive health care. Comprehensive, high-quality care addresses issues, challenges, and opportunities unique to children and young adults and addresses the effects of historic and present inequities. All families should have equitable access to professionals and facilities with expertise in the care of children within a reasonable distance of their residence. Payment methodologies should be structured to guarantee the economic viability of the pediatric medical home and of pediatric specialty and subspecialty practices. The recent increase in child uninsurance over the last several years is a threat to the well-being of children and families in the short- and long-term. Deficiencies in plans currently covering insured children pose similar threats. The AAP believes that the United States must not sacrifice recent hard-won gains for our children and that child health care financing should be based on the following guiding principles: (1) coverage with quality, affordable health insurance should be universal; (2) comprehensive pediatric services should be covered; (3) cost sharing should be affordable and should not negatively affect care; (4) payment should be adequate to strengthen family- and patient-centered medical homes; (5) child health financing policy should promote equity and address longstanding health and health care disparities; and (6) the unique characteristics and needs of children should be reflected.

Insurance Status and Tumor Necrosis Factor Inhibitor Initiation Among Children With Juvenile Idiopathic Arthritis in the CARRA Registry

OBJECTIVE

Prompt escalation to tumor necrosis factor inhibitors (TNFis) is recommended for children with juvenile idiopathic arthritis (JIA) and ongoing disease activity despite treatment with conventional disease-modifying antirheumatic drugs (cDMARDs). It is unknown whether these recommendations are equitably followed for children with different insurance types. We assessed the association of insurance coverage on the odds and timing of TNFi use.

METHODS

We conducted a retrospective study of children with newly diagnosed JIA in the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry. We compared the odds of starting a TNFi in the first year and time from cDMARD to TNFi initiation between those with public and private insurance.

RESULTS

We identified 1086 children with new JIA diagnoses. Publicly insured children had significantly higher active joint counts and parent/patient global assessment scores at the enrollment visit. They were also more likely to have polyarticular arthritis compared to those with private insurance. Odds of any TNFi use in the first year did not differ between publicly and privately insured children. Publicly insured children were escalated from cDMARD to TNFi more quickly than privately insured children.

CONCLUSION

Children who were publicly insured had more severe disease and polyarticular involvement at registry enrollment compared to those who were privately insured. Whereas overall TNFi use did not differ between children with different insurance types, publicly insured children were escalated more quickly, consistent with their increased disease severity. Further research is needed to determine why insurance coverage type is associated with disease severity, including how other socioeconomic factors affect presentation to care.

Pediatric COVID-19 Health Disparities and Vaccine Equity

While most children with coronavirus 2019 (COVID-19) experience mild illness, some are vulnerable to severe disease and develop long-term complications. Children with disabilities, those from lower-income homes, and those from racial and ethnic minority groups are more likely to be hospitalized and to have poor outcomes following an infection. For many of these same children, a wide range of social, economic, and environmental disadvantages have made it more difficult for them to access COVID-19 vaccines. Ensuring vaccine equity in children and decreasing health disparities promotes the common good and serves society as a whole. In this article, we discuss how the pandemic has exposed long-standing injustices in historically marginalized groups and provide a summary of the research describing the disparities associated with COVID-19 infection, severity, and vaccine uptake. Last, we outline several strategies for addressing some of the issues that can give rise to vaccine inequity in the pediatric population.

Management of Chronic Migraine in Children and Adolescents: Where are We in 2022?

Migraine is a neurological disorder that affects millions of children and adolescents worldwide. Chronic migraine is a subtype of migraine in which patients experience headaches for more days than not each month, with accompanying symptoms of phonophobia, photophobia, nausea or vomiting for most of these headaches. The burden and impact of chronic migraine in the daily lives of children and adolescents is substantial, requiring a holistic, multidisciplinary, and biopsychosocial approach to conceptualization and treatment. The purpose of this review is to provide a comprehensive “2022” overview of acute and preventive treatments for the management of chronic migraine in youth. We first describe diagnostic criteria for chronic migraine and highlight the state of evidence for acute and preventive treatment in children and adolescents. We then discuss emerging treatments currently receiving rigorous clinical research effort, special considerations for the treatment of chronic migraine in children and adolescents, and avenues for improving existing treatments and expanding access to evidence-based care.

Pediatric Health Access and Private Medical Insurance: Based on the Ecology of Medical Care in Korea

This study aimed to investigate pediatric health access by describing the ecology of medical care for children and adolescents in a medical environment where a well-balanced system between national health insurance (NHI) and private medical insurance (PMI) is required. Data from 2746 individuals aged 18 years old and younger were used. Of the participants, 87.3% had private medical insurance. Of the 1000 children, in an average month, 404 visited a clinic, 67 visited a hospital outpatient department (OPD), 49 visited an OPD in a tertiary hospital, 11 received emergency care, 5 received inpatient care in a hospital, and 9 were hospitalized. The generalized estimating equation models adjusted for age, sex, economic status, and pediatric comorbidity index were used for multivariate analysis. Receiving ambulatory care services in clinics was significantly more likely among children and adolescents with private medical insurance (adjusted odds ratio [aOR] = 1.16 [95% confidence interval [CI]: 1.00-1.35]). Receiving ambulatory care services in clinics was significantly more likely among indemnity type policyholders (aOR = 1.23 [1.05-1.45]) and single policyholders (aOR = 1.18 [1.00-1.37]). Countries with national health insurance schemes should continuously practice the proper regulation and management of PMI, including reviewing PMI compensation measures, NHI reimbursement standards, and consumers' perspectives on NHI and PMI.

Insurance Delays in Initiation of Tumor Necrosis Factor Inhibitors in Children With Juvenile Idiopathic Arthritis

This cohort study compares the delays in tumor necrosis factor inhibitor (TNFi) initiation because of insurance among children enrolled in public and private insurance plans.