Published online August 1, 2005
PEDIATRICS
Vol. 116
No. 2
August 2005, pp.
345-351
(doi:10.1542/peds.2004-2085)
Unworried Parents of Well Children: A Look at Uninsured Children Who Reportedly Do Not Need Health Insurance
Stephen J. Blumberg, PhD*,
Kathleen S. O'Connor, MPH* and
Genevieve Kenney, PhD
* Centers for Disease Control and Prevention, National Center for Health Statistics, Hyattsville, Maryland
Urban Institute, Washington, DC
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ABSTRACT
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Objectives. We examined the characteristics of uninsured children from low-income households whose parents reported that health insurance coverage was not needed.
Methods. With data from the 2001 National Survey of Children With Special Health Care Needs, we used logistic-regression analyses to investigate the odds of reporting that uninsured children do not need insurance for various sociodemographic groups and children of varying health status. We also explored the odds of health care use, awareness of Medicaid and the State Children's Health Insurance Program (SCHIP), and desire to enroll according to the reported need for insurance.
Results. Parents of 6.8% of uninsured children from low-income households reported that their children did not need insurance. Rates were highest for American Indian/Alaska Native children (15.2%) and children whose parents completed the interview in a non-English language (10.6%). Rates were lowest for children with special health care needs (2.8%) and children with 
7 school absences attributable to illness or injury in the past year (2.6%). Relative to children with another reason for lacking insurance, children who reportedly did not need insurance were less likely to have needed (adjusted odds ratio: 0.49) or used (adjusted odds ratio: 0.45) health care services in the past year and their parents were less likely to have heard of Medicaid or SCHIP (adjusted odds ratio: 0.58) or to have a desire to enroll their children if their children were eligible for Medicaid or SCHIP (adjusted odds ratio: 0.25).
Conclusions. Increasing participation among uninsured children whose parents do not perceive a need for insurance coverage may require more than simply increasing knowledge about the availability of public insurance programs.
Key Words: health insurance coverage gaps • health service utilization • parental attitudes • parental beliefs
Abbreviations: CSHCN, children with special health care needs • SCHIP, State Children's Health Insurance Program • AIAN, American Indian/Alaska Native
The 2003 National Health Interview Survey revealed that 10.1% of children <18 years of age were uninsured at the time of the interview, a decrease of 3.8 percentage points since 1997.1 Of the uninsured, 
67% with reported income lived in families with low income (<200% of the federal poverty level). Most of those children would have been eligible for government insurance programs such as Medicaid and the State Children's Health Insurance Program (SCHIP). It is often assumed that parents would be eager to enroll their uninsured children in these programs were it not for various structural impediments (eg, complex and burdensome program applications), language and literacy difficulties, or the stigma of public program participation.2–6 Indeed, the majority of low-income parents stated that they would enroll their children in Medicaid or SCHIP if they were told their children were eligible for Medicaid or SCHIP.7
However, the 1999 National Survey of America's Families revealed that 22.1% of uninsured children from low-income families had parents who said that public coverage was not needed or wanted.8 Analyses of their health and health care needs revealed that these children, relative to other uninsured children from low-income families, tended to be in better health and have fewer unmet needs. This article presents a more extensive examination of the same topic, with a broader focus on coverage in general (rather than just public coverage) and with a larger and more recent data set from the National Center for Health Statistics, Centers for Disease Control and Prevention.
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METHODS
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Data Source
The 2001 National Survey of Children With Special Health Care Needs provides data from the largest sample to date of the population of uninsured children in the United States. This random-digit-dial telephone survey screened 373055 children <18 years of age for special health care needs. Within each household with children, up to 1 child with special needs and 1 child without special needs were selected randomly for an interview that included questions about health insurance coverage and demographic characteristics.9
The interview also included questions about health status, health care access, and utilization. For children with special health care needs (CSHCN), these questions preceded the health insurance questions. For uninsured children without special needs living in low-income households (<200% of the federal poverty level) or in households with unreported income, these questions were asked at the end of the interview. For children without special needs who were either insured or living in higher-income households, the questions about health and health care were not asked.
The 2001 National Survey of Children With Special Health Care Needs was conducted from October 2000 to April 2002. Surveys were completed in English and in 11 other languages, with translated questionnaires and multilingual interviewers. Spanish was the most common non-English language (88% of completed non-English interviews). The respondent was the parent or guardian who knew the most about the child's health and health care. The weighted overall response rate was 61.8%.10
Key Variables
Parents and guardians of uninsured children living in low-income households were asked for "the main reason [the child] does not have health insurance now" and "any other reasons." Open-ended responses were categorized by the interviewer into 1 of 11 predetermined categories. Answers that could not be categorized easily were recorded verbatim and, when possible, were coded later by data collection supervisors into 1 of the original 11 categories or 1 of 11 new categories that were created after identification of commonalities among the verbatim responses.10 Questions on the number of visits to doctors or other health care providers and the number of school days missed because of illness and injury were also open-ended and were reported for the previous 12 months (or since birth for children <12 months of age).
Needs for health care were determined with 9 questions about needs during the previous 12 months for well-child check-ups; specialty care; dental care; prescription medicine; physical, occupational, or speech therapy; mental health care; substance abuse treatment; eyeglasses or vision care; and hearing aids or hearing care. Unmet needs were identified with questions regarding whether the child received all of the specific types of care needed. Out-of-pocket expenses for medical care for the child during the previous 12 months did not include health insurance premiums and were reported with 6 categories. CSHCN were identified with a 5-item screen.11
Parents and guardians of uninsured children living in low-income households were asked whether they had ever heard of Medicaid or the state-specific Medicaid program name. An additional question asked whether they had ever heard of SCHIP or the state-specific SCHIP program name. When a state had a SCHIP program with the same name as its Medicaid program, the SCHIP awareness question was not asked. For children from Alaska, Arkansas, the District of Columbia, Idaho, Louisiana, Nebraska, New Mexico, or Wisconsin, the SCHIP awareness question used the state-specific name of the Medicaid expansion program funded by Title XXI.
If the parents or guardians had heard of either Medicaid or SCHIP, then they were asked whether the child had ever been enrolled in either program and, if not, whether the parent had ever applied for either program. Parents were also asked, "Based on what you know about [the programs], do you think your child is eligible now?" and "If you were told your child were eligible for [the programs], would you want to enroll [him/her]?" Answers of "don't know" to these latter 2 questions were treated as negative answers for the analyses reported here.
All other variables reported were asked as single questions with discrete answer categories. Answers of "don't know" and "refuse to answer" were treated as missing data with the exceptions of household income and the 2 questions noted above.
Analyses
Health insurance coverage information was available for 215162 randomly selected children.12 Of these children, 10930 children were identified as uninsured and were either living in low-income households or did not have income reported and were later designated as low income on the basis of imputation.13 (For simplicity, these children are hereafter referred to as "low-income uninsured children.") Reasons for lack of insurance were not available for 1757 of these children because their parents incorrectly thought that they had comprehensive insurance coverage (280 were covered only by the Indian Health Service and 38 were covered only for dental care or other single services), their parents did not know or refused to provide reasons for their children's lack of insurance (n = 329), or their parents were not asked these questions because of a computer programming error (n = 1110). The analyses in this article were based on the remaining 9173 low-income uninsured children for whom reasons were provided.
For various sociodemographic groups and for children of varying health status, logistic regression analyses were used to examine the odds of reporting that the uninsured child did not need health insurance. Additional logistic regression analyses explored the odds of health care access, utilization, and expenses for children who reportedly did not need health insurance, relative to children with other reported reasons for lack of insurance. The latter represented the reference group. Similar logistic regression analyses considered the odds of prior Medicaid or SCHIP enrollment, stated willingness to enroll, and beliefs about current eligibility; again, children with other reported reasons for lacking insurance represented the reference group. The analyses used sampling weights to produce population-based estimates that are nationally representative. The sampling weights reflect the unequal probability of selection of each child and are adjusted to compensate for the complex survey design, survey nonresponse, and noncoverage of households without telephones. All analyses were conducted with SUDAAN, which accounts for the survey design in estimations of SEs and confidence intervals.14
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RESULTS
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When asked why their children did not have health insurance, parents of 6.8% of the low-income uninsured children (SE: 0.5%) gave answers that were categorized as "do not need insurance/do not get sick." This answer was the main reason for lack of insurance for 5.5% (SE: 0.5%; n = 457) of the low-income uninsured children and was a secondary reason for an additional 1.3% (SE: 0.2%; n = 131) of low-income uninsured children. The most common reasons for lacking insurance were cost and an inability to obtain insurance through employers (Table 1).
The demographic distribution of the children who reportedly did not need insurance is presented in Table 2. Within each demographic group, Table 3 presents the proportion of the low-income uninsured children who reportedly did not need insurance. For example, Table 2 shows that adolescent children constituted 41.8% of the total population of low-income uninsured children, whereas Table 3 shows that, among low-income uninsured adolescent children, 8.1% reportedly did not need insurance. Table 3 also shows that adolescent children were more likely to reportedly not need insurance, relative to children 6 to 11 years of age.
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TABLE 2. Sociodemographic Composition of the Population of Low-Income Uninsured Children Whose Parents Said Health Insurance Was Not Needed: United States, 2001
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TABLE 3. Proportion of Low-Income Uninsured Children Whose Parents Said Health Insurance Was Not Needed and Relative Odds of Reportedly Not Needing Insurance: United States, 2001
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Non-Hispanic children of American Indian/Alaska Native (AIAN) race were only a small proportion of the total population of low-income uninsured children (4.0%), but low-income uninsured AIAN children were more likely than low-income uninsured children from any other racial/ethnic group to reportedly not need insurance (15.2%). The odds of reportedly not needing insurance were >5 times as great for AIAN children, compared with non-Hispanic white children, after adjustment for the other sociodemographic characteristics in Table 3.
Hispanic children were also more likely than non-Hispanic white children to reportedly not need insurance (8.9% and 3.2%, respectively). However, after adjustment for the language of the interview and the other sociodemographic characteristics in Table 3, the relationship of Hispanic ethnicity to reported need for insurance was not statistically significant (odds ratio: 0.96, relative to non-Hispanic white race). Many of the low-income uninsured children who were Hispanic had parents who did not speak English (80.2%), and most of the low-income uninsured children whose parents did not speak English were Hispanic (96.0%). With both language of interview and ethnicity in the regression model, the model revealed that language of interview had a stronger relationship to reports of not needing insurance. The odds of reportedly not needing insurance were nearly 3 times greater for children whose parents completed the interview in a non-English language, compared with the odds for children whose parents completed the interview in English.
Children who were healthier were more likely to reportedly not need insurance. Table 3 shows that, even after controlling for sociodemographic characteristics, CSHCN and children with 7 school absences attributable to illness or injury had odds of reportedly not needing health insurance that were one half the odds for correspondingly healthier children. Therefore, it was perhaps not surprising to note that children who reportedly did not need insurance were less likely to need health care services, to have unmet health care needs, to have a personal doctor or nurse, to have had a doctor's visit in the past year, to have had health care expenses that exceeded $1000 in the past year, and to have parents who reported financial problems attributable to the child's health care (Table 4). These differences in health care access and utilization remained statistically significant even after controlling for special health care needs and for school absences.
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TABLE 4. Relative Odds of Health Care Access, Utilization, and Expenses for Low-Income Uninsured Children, According to Reason for Lack of Health Insurance Coverage: United States, 2001
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It was more surprising that approximately one half of the children who reportedly did not need insurance had parents who had heard of Medicaid or SCHIP and said they would enroll their children in Medicaid or SCHIP if told they were eligible (53.5%, or the product of 84.0% and 63.7%) (Table 5). Although this was substantially lower than the estimate for the children with another reason for lacking insurance (78.6%, or the product of 91.6% and 85.8%), it was still higher than might be expected, given the parents' statements that insurance was not needed. Although most parents had heard of Medicaid, the children who reportedly did not need insurance were less likely to have parents who had heard of either of the public health insurance programs in their state. They were also less likely to have been enrolled in Medicaid or SCHIP at some point in their lives.
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TABLE 5. Relative Odds of Awareness of, Experience With, and Intentions to Enroll in Medicaid or SCHIP for Low-Income Uninsured Children, According to Reason for Lack of Health Insurance Coverage: United States, 2001
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DISCUSSION
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Economic approaches to understanding health insurance enrollment suggest that parents enroll their children when the benefits exceed the costs.15,16 Parents' perceptions of benefits would be expected to depend partly on the potential recipient's health status.17 Indeed, parents of uninsured children with recent emergency department visits, hospitalizations, or acute care visits were more likely to enroll in SCHIP,18 and the proportion of CSHCN in SCHIP was greater than the proportion of CSHCN in the general population.19 Participation in Medicaid and private insurance has also been shown to be related to health status.20,21
The present results confirm that parents' perceptions of the need for insurance are related to children's health status and health care use. Compared with other low-income uninsured children, those who were said to not need insurance were less likely to be reported as needing health care or going without needed care. Health care expenses were lower for these children, and nearly all parents who reported no need for insurance indicated that the uninsured child's health care did not cause financial problems for the family.
The causal direction of the relationship between perceived need for health insurance and perceived need for health care cannot be determined directly from the present data. It is worth noting, however, that differences in reported health care needs remained after controlling for characteristics that included special health care needs status and prior-year school absences, which suggests that parents' perceptions of health care needs are somewhat independent of these 2 measures of prior-year health status. Some parents may simply lack knowledge of standards for appropriate health care, which could result in lower perceived need for health care and insurance to pay for that health care.
For example, many children who reportedly did not need health insurance were not receiving the preventive care that is recommended by pediatricians.22 Fewer than 50% had had a doctor's visit in the past year, including preventive check-ups. Nearly 50% of the children had parents who did not recognize any need for a well-child check-up, a dental check-up, or any other type of health care in the past 12 months. Many of these children did not have a medical home; that is, >40% did not have a usual place for sick care, and nearly two thirds did not have a personal doctor or nurse. Some parents may not know that children without a medical home are at greater risk of emergency department use, hospitalizations, and delayed or inaccurate diagnoses.23 These parents may not appreciate the importance of insurance.
It is reassuring that the proportion of low-income uninsured children reported to not need insurance was low for every demographic subgroup examined. Moreover, approximately one half of the children who reportedly did not need coverage had parents who said they would enroll them in Medicaid or SCHIP if they were told the child was eligible. However, 16% of these children had parents who were not aware of these public health insurance programs; of those whose parents had heard of these programs, one half had parents who did not think that the child was eligible.
Lack of awareness of preventive care needs for healthy children, the perceived need for insurance, the availability of low-cost public health insurance programs, and the eligibility of most children from low-income households were related to sociocultural characteristics. For example, nearly two thirds of the low-income uninsured children who reportedly did not need insurance had parents who did not speak English. These parents were likely to be recent immigrants, who might have had experiences with health care and health insurance that differed from those of long-time US residents. In addition, although AIAN children were only a small proportion of the total population of low-income uninsured children, they were more likely than low-income uninsured children from any other racial/ethnic group to reportedly not need insurance. Their parents might think that Indian Health Service facilities would be sufficient to meet their children's medical needs, not recognizing that uninsured AIAN children using the Indian Health Service receive less preventive care than insured AIAN children.24
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CONCLUSIONS
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Many low-income parents of uninsured children do not know about the availability of and their child's eligibility for low-cost insurance plans.25 However, the majority of children who reportedly did not need insurance had parents who said they would enroll their children in Medicaid or SCHIP if they were told their children were eligible for coverage. This result suggests that many low-income uninsured children could be enrolled in health insurance programs if their parents learned of their eligibility. However, for parents of the small fraction of uninsured children who were generally reported to be healthy and to not need insurance (ie, the unworried parents of well children), learning about eligibility might not be sufficient to motivate participation in Medicaid, SCHIP, or other insurance programs.
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ACKNOWLEDGMENTS
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The National Survey of Children With Special Health Care Needs was sponsored by the Health Resources and Services Administration, Maternal and Child Health Bureau, and it was fielded as part of the State and Local Area Integrated Telephone Survey by the Centers for Disease Control and Prevention, National Center for Health Statistics. Additional funding for the supplemental questions for low-income uninsured children was provided by the US Department of Health and Human Services as part of the congressionally mandated evaluation of SCHIP [42 USC 1397hh(c)].
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FOOTNOTES
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Accepted Dec 2, 2004.
Address correspondence to Stephen J. Blumberg, PhD, National Center for Health Statistics, Centers for Disease Control and Prevention, 3311 Toledo Rd, Room 2112, Hyattsville, MD 20782. E-mail: sblumberg{at}cdc.gov
The statements contained in this article are solely those of the authors and do not necessarily reflect the views or policies of the agencies that funded the data collection.
No conflict of interest declared.
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ABSTRACT
METHODS
