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Access to healthcare in childhood has long term effects on health outcomes, but many children in the US are either uninsured or underinsured, meaning they often don’t have access to the care they need. Why is that and what can we do about it?

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Access to healthcare in childhood has individual and society-level benefits that can last a lifetime. However, the number of children who are either underinsured or lack insurance altogether in the United States has risen somewhat dramatically in recent years. Why that matters and what we might do about it are the topic of this week's Healthcare Triage.

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A recent analysis in JAMA Pediatrics reported that the number of uninsured children in 2019 was 6.3 million, up from 5.9 million in 2016. During this same period, the number of underinsured children went from 16.2 million to 18.1 million. According to that analysis, children with private insurance were more likely to have inadequate coverage than those on public insurance. Inadequate coverage was also more common among adolescents, Hispanic and white children, children with existing medical problems such as diabetes and autism, and children in non-English-speaking families and families with middle incomes.

For both uninsured and underinsured children, access to healthcare is more difficult, and when they are able to access it, the care is more likely to be suboptimal. For children without health insurance, needed treatments are more likely to be delayed, and they often don't receive preventative care visits, such as well-child visits.

These issues exist for underinsured children as well. Although they have insurance, there are limitations that make it difficult for them to receive adequate care. One of the major limitations is cost sharing - things like deductibles and co-pays that are simply too high for parents to afford. Another is limited coverage of needed services, with some services being limited to a certain amount and some services being excluded altogether.

For example, things like nutritional counseling and behavior or mental health therapies are least likely to be covered at appropriate levels. These services can be particularly important in the adolescent age group, where conditions such as anorexia and mood disorders are more likely.

Many uninsured children are eligible for public insurance, so outreach efforts to enroll them may help decrease these numbers. Retention efforts can also help. One example is continuous eligibility, where children retain 12 months of continuous public health insurance regardless of changes to family income.

Addressing affordability will help bring these numbers down. The introduction of the Affordable Care Act made an enormous difference, but there are still many adults who cannot afford a health plan or cannot afford a plan that adequately meets their needs. The American Rescue Plan, passed in March, helped by addressing Medicaid eligibility gaps and increasing subsidies for coverage through the marketplace.

That's all great, but work still needs to be done to address underinsurance issues with private plans. As written by some of my health research colleagues in the Washington Post, high-deductible plans offered by employers are a large part of our problem with underinsurance. People struggle to afford annual deductibles that range, on average, from over $2500 a year to over $5000 a year. Another part of the problem are short-term healthcare plans, which can have low premiums but don't cover many basic services or preexisting conditions.

Their article also offered suggestions to offset some of these issues, including government incentives for employers to cover more services and to make more of those services exempt from deductibles. Other incentives could be offered to encourage to take some of the cost off the shoulders of their lowest paid workers. They could also invest in professionals who can help their employees choose adequate plans by helping them understand more about their options, like if a low premium plan will saddle them with an unmanageably high deductible or with a plan that doesn't cover services they'll likely need.

You might think we've gone off track here, talking about how we can help adults gain better coverage, when we started this episode talking about kids, but better healthcare coverage for parents means better coverage for the children on their plans. Furthermore, research suggests that enrollment in public health insurance increases for children when coverage is expanded to their parents.

It seems obvious, and data suggests, that access to healthcare affects outcomes long after childhood, and it affects more than just health outcomes. For example, one 2020 study reported a link between Medicaid eligibility expansions in childhood and outcomes in adulthood including lower mortality, increased college enrollment, an increase in taxes paid, and a decrease in the use of the earned income tax credit. Better access to quality healthcare benefits everyone. We need to make it happen.

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