Reviewing Consistency and Adequacy of Public vs. Commercial Health Insurance for American Children

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New research reveals significant insurance gaps among both publicly insured and commercially insured children. In a study published last month by JAMA Network Open, researchers aimed to discover how the rates and child and family characteristics associated with inadequate and inconsistent health insurance coverage compare for publicly vs commercially insured children in the United States. Furthermore, investigators sought 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.1

Relying on a cross-sectional study using nationally representative data from a national survey of children’s health from those aged 0 to 17 years from 2016-2021, investigators discovered that:

  • Publicly insured children had higher rates of inconsistent coverage (gaps in the past year) compared to commercially insured children (4.2% vs. 1.4%).
  • Commercially insured children faced higher rates of inadequate coverage (12.2% vs. 33.0%), defined by insufficient benefits, restricted access to healthcare practitioners, and high out-of-pocket payments.
  • Both public insurance consistency and commercial insurance adequacy improved substantially during the COVID-19 public health emergency (2020-2021).
  • The challenges faced by publicly and commercially insured children differed, emphasizing the need for tailored policy solutions.1

Additionally, rates of children who were uninsured appear to have worsened during the final full year of the COVID-19 pandemic, according to a new analysis of 2022 census data of children, specifically in Pennsylvania. The 2023 State of Children’s Health in Pennsylvania report showed that more than 145,000 children in the state are without health insurance.2

“We did see the uninsured rate get worse for children; it went up to 5.2%,” explained Becky Ludwick, VP, public policy, Pennsylvania Partnerships for Children. “And that’s a pretty significant increase from the previous year, which was 4.4%. And we were surprised because we expected at least stable or improvements to the coverage, like many other states have seen during this latest census round.”

Ludwick also pointed out in an interview with Public News Service that children are facing greater barriers to accessing health insurance compared with adults, citing that despite being eligible for Medicaid, many children might not be properly enrolled. She further anticipated that next year’s data may show an even more concerning decline in coverage, urging the Department of Health and Human Services to take a couple of actions they think could help better connect kids to coverage.2

“First is to immediately restore coverage for children who lost coverage during the unwinding of the Medicaid continuous coverage provision, due to an error in how the state was determining eligibility,” she told Public News Service.

The study findings raise a number of implications, the first of which being the necessity for postpandemic policies that address the unique challenges faced by each population of insured children to enhance the consistency and quality of health coverage. Second, publicly insured children faced issues of insurance gaps, while commercially insured children experienced inadequacies, particularly related to out-of-pocket costs. Third, the findings highlight the importance of continuous Medicaid eligibility, streamlined enrollment processes, and targeted outreach to address insurance gaps for publicly insured children. Finally, affordability emerged as a major concern for commercially insured children, indicating a need for policy measures to improve insurance adequacy, such as expanded Medicaid-CHIP coverage and enhanced subsidies for ACA Marketplaces.1

“This cross-sectional study found that publicly insured children have higher rates of inconsistent coverage, but considerably lower rates of inadequate coverage compared with commercially insured children,” the authors concluded. “Inadequate coverage affects a far large share of US children overall, primarily due to high OOP costs for those with commercial insurance. Policies are urgently needed to maintain and build on PHE-era gains in public insurance consistency and commercial insurance adequacy to ensure that all US children have affordable access to high-quality health care.”


1. Consistency and Adequacy of Public and Commercial Health Insurance for US Children, 2016 to 2021. JAMA Network. November 22, 2023. Accessed December 1, 2023.

2. PA sees drop in health insurance coverage for children as national rates rise. Public News Service. November 16, 2023. Accessed December 1, 2023.

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