91% of U.S. children are insured, survey finds

Coverage varies greatly from state to state, with Massachusetts at 98.5% and Nevada at 81.6%.

By Marcia Frellick amednews correspondent — Posted Nov. 8, 2010

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In 2009, nearly 1% more children in the United States had health insurance than the year before. That brought the total of coverage for those 18 and younger to 91%, according to data recently released by the American Community Survey.

But coverage varied widely from state to state. Massachusetts, with mandated health insurance for adults, had the highest percentage of insured children, with 98.5% covered. Nevada had the lowest at 81.6%, according to the survey the U.S. Census Bureau conducts annually by sampling 3 million households.

"We are making progress," said Julie Sonier, a senior research fellow at the University of Minnesota School of Public Health, who analyzed the 2008 ACS data. "Between 1995 and 2008, the rate of uninsurance for kids fell from 12.6% to 9.1%. During the same time, [the uninsurance rate] was going up for adults. But there are still significant issues among certain groups of kids," which puts them at greater risk for health problems.

Insured children are generally in better health, according to the Institute of Medicine's 2002 report, "Health Insurance is a Family Matter."

Without insurance, they are less likely to have a primary care physician and more likely to receive care late in the development of a health problem, the study showed.

David Gremse, MD, chair of the Dept. of Pediatrics at the University of Nevada School of Medicine, said two main factors may be lowering the number of children who have insurance in his state. First, although a child often qualifies for Medicaid through the Children's Health Insurance Program, the parent either isn't aware that the child is eligible, or knows about the program but doesn't apply. "We have more of a transient population with less community connectedness and awareness of public services," Dr. Gremse said.

Another problem for Nevada is the large number of children who are U.S. citizens but whose parents are undocumented, Dr. Gremse said. A Pew Hispanic Center analysis of census data through March 2009 found that Nevada, which has an undocumented immigrant population of 6.8%, ranked second-highest in the nation, behind only California.

In those families, parents may be reluctant to apply for services because they worry about interacting with government agencies.

"If the children don't have coverage, there are very few clinics and physicians in the area who are willing to see those children on a volunteer basis," Dr. Gremse said.

The result is that children with special health care needs and chronic conditions often end up in emergency departments for care, he said.

Coverage loss caused by recession

Overall, the ACS data showed that the percentage of uninsured children decreased in 17 states, and did not change significantly in 31 states, the District of Columbia and Puerto Rico. Minnesota and Alaska were the only two states in the survey with statistically significant increases in the number of uninsured children.

Marilyn Peitso, MD, president of the Minnesota chapter of the American Academy of Pediatrics, said she suspects that the less than 1% decrease in the number of insured children is a result of parents losing their jobs -- and the insurance that came with them -- during the recession. At the CentraCare Clinic in St. Cloud where she practices, she said, the number of self-pay patients increased to 5% in the first quarter of 2008, up from 3% in 2007.

"We have noticed an increase in people saying, 'I'm losing my job, and we want to get everything done today, because we don't know if we'll be able to come back,' " Dr. Peitso said.

But Minnesota historically has been among the states with low uninsurance rates -- 6.2% in 2008. The University of Minnesota School of Public Health researchers found that some children in Minnesota are more likely to be uninsured than others.

"There are many states where there's a low uninsurance rate for children, but the gaps between white and Hispanic are very large," Sonier said. "The uninsurance rate for Hispanic children in Minnesota was 22.5%, and it was 4.6% for white children."

The researchers -- who compared states' coverage of children among age subgroups, income and ethnic groups -- found that most states had gaps in at least one area.

"The message is across the board there are things states can be looking at to improve kids' coverage -- either as an overall strategy or targeting the groups that don't do as well as others," Sonier said.

Even in Massachusetts, which has the nation's best coverage rate for children, ethnic disparities emerged from previous ACS data. Health Care for All, an independent, statewide consumer advocacy organization, found pockets of uninsured largely among Hispanic and Portuguese families. Teams are targeting those groups in their outreach.

"Every child in the Commonwealth of Massachusetts is eligible for some type of free or lower-cost health care coverage option through the state if they can't get it through their parents' work and sometimes even if they can and meet other circumstances," said HCFA help line manager Kate Bicego.

The organization is working with ethnic media outlets to connect the last 17,000 uninsured children in Massachusetts with affordable insurance through Medicaid and the state's Health Connector exchange program, which helps families find insurance and avoid tax penalties.

From private to public

The ACS data showed a shift in the kind of insurance under which children were covered. There were fewer privately insured children and more who received public coverage.

The number of children with private coverage -- primarily employer-based and direct purchase -- stood at 48.9 million in 2009, down from 50.5 million in 2008 as the country was embroiled in recession.

From 2008 to 2009, the number of families with at least one unemployed member rose to 9.4 million, up from 6.1 million, according to the Bureau of Labor Statistics.

The number of children who had public coverage -- primarily Medicaid -- increased from 32.7% to 35.7%.

Two federal laws increased access to public coverage in 2009. The federal government reauthorized CHIP, which increased the number of children covered from 7 million to nearly 11 million. And the 2009 economic stimulus package helped states maintain and expand Medicaid services.

"There's a pretty long-term trend toward declining rates of private coverage," Sonier said.

"Public coverage has offset some of that, but not all of it. ... You need a balanced strategy of stopping the erosion on the private side while making sure the safety net of public coverage is there."

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Uninsured rates down

In 2009, the percentage of uninsured children decreased in 17 states and did not change significantly in 31 states, the District of Columbia and Puerto Rico. Minnesota and Alaska were the only states with statistically significant increases in the number of uninsured children. All numbers are given in thousands.

Source: "Health Insurance Coverage of Children Under Age 19: 2008 and 2009," U.S. Census Bureau, September (link)

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