Underinsurance (healthcare)

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Underinsurance is the state of an individual having some form of health insurance that does not offer complete financial protection. This results in the underinsured individual to therefore lack the ability to cover out-of-pocket healthcare expenses. There is not yet one clear definition that has been established to include all of the domains that must be addressed. There are three domains that are included when considering underinsurance in healthcare. They include; (1) the economic characteristics of health insurance, (2) the benefits that are or are not covered, and (3) actual access to health services and resources. All of these aspects must be considered when defining, measuring, and identifying instances of underinsurance.[1]

The term “uninsured” is often better known and more often discussed. This is because it has a clear definition of an individual not possessing health insurance coverage. This clearly defined term allows for accurate measurements of the number of uninsured people, and more reliable research results. However, an individual being underinsured, or experiencing underinsurance is much more difficult to research and measure. This is because there is not one simple clear-cut definition of underinsurance. Rather there are three different types of definitions that are most commonly discussed; economical, attitudinal and structural. This difficulty and inconsistency in defining the term has led to a lack of research and knowledge of the topic.[2] It has been established that individuals who are categorized as underinsured, are at high financial risk, and face barriers in the level of access to care. This difficulty in access to care is similar to those who are completely uninsured.[3]

Definition differences[edit]

Economical Underinsurance[edit]

The economic definition of underinsurance is a person's actual ability to pay for their recommended health care and services. This includes the cost of the insurance premiums, co-payments, and deductibles. An economic definition of underinsurance specifically defines a certain monetary limit above which the expenses of health care coverage become a significant financial burden, and interfere with access to care. This definition of underinsurance is utilized and identified when an individuals' out-of-pocket expenses for necessary medical care are above a specified percent of that individual's income, within a given time frame. This definition is also used when a person chooses to delay, or not receive necessary health care services solely because of the out-of-pocket costs associated with the services.[3]

Attitudinal Underinsurance[edit]

Attitudinal definitions are derived from the consumers' perceptions, (as opposed to factual monetary limits) as well as their satisfaction in regards to health care. This definition leaves more opportunities for individual interpretation as compared to that of the economical and structural underinsurance definitions. The attitudinal underinsurance definition is recognized when; (1) at least one health benefit that the individual would prefer to receive is not covered by insurance, (2) when there is at least one symptom that the person believed required treatment for which insurance coverage treatment was not provided, or (3) when a person is dissatisfied with their insurance plan.[1] Because there adequate room for personal interpretation in this definition, surveys that are conducted using this definition often are not always as well accepted when compared to surveys that are conducted using the structural and economical definitions.

Structural Underinsurance[edit]

Structural definitions of insurance, generally consider both the type of benefits that are offered by the healthcare insurance program, as well as the number and range of providers whose services are covered under the identified plan. A structural approach to defining underinsurance uses a benchmark benefits package as a basis of comparison. Structural underinsurance is utilized when at least one benefit in the benchmark package is not covered by the individual's health insurance plan.[4]

At risk populations and situations[edit]

Children with Special Health Care Needs[edit]

Children with Special Healthcare Needs (CSHCN) have been the most highly research population that experiences the effects of underinsurance.[1] CSHCN have been routinely been defined as those who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally.[5] All children who have been identified as CSHCN must be considered and taken into account when research is being conducted to further identify who is at risk for experiencing underinsurance.[6]


The number of vaccines that are recommended for children under 5 years old living in the United States experienced a significant increase, nearly doubling in the past ten years. With these recommendations and requests for further vaccinations, the cost for vaccinating a child has become increasing expensive.[7] The differences in health insurance coverage (private vs. public), along with the current vaccine financing system that is in place, together have combined to result in significant gaps in vaccination coverage and distribution for children in the U.S. These gaps then translate into children being underinsured and not having the ability to receive access to recommended and required vaccinations.

Vaccines For Children (VFC) is a federally funded, state managed program that allows children to receive vaccines free of cost for families that may not otherwise be able to afford them. 16 vaccinations are recommended by the Advisory Committee on Immunization Practices (ACIP) available through the VFC program.[8] The VFC program has over 44,000 doctors enrolled nationwide.[9] Children who are underinsured (their health insurance does not cover the cost of all or certain vaccines, or their parents are not able to pay the fixed dollar co-pay amount that is required) are able to receive vaccines Federally Qualified Health Centers (FQHC), and Rural Health Clinics (RHC).[10] 16 recommended children's vaccinations are available through the VFC program

Diphtheria Human Papillomarvirus (HPV) Mumps Rotavirus
Haemophilus influenzae (type b) Influenza (flu) Pertussis (whooping cough) Rubella (German measles)
Hepatitis A Measles Pneumonococcal disease Tetanus (lockjaw)
Hepatitis B Meningococcal disease Polio Varicella (chickenpox)

Effects of Underinsurance in Healthcare[edit]

When concerned with medical care and services, it has been shown that people who are experiencing the repercussions of underinsurance behave a lot like those individuals who are uninsured. Individuals often don't visit the doctor, don't fill prescriptions, and don't undergo preventive checkups and lab tests.[11] Even when they go without preventive care and necessary prescriptions, many of the undersinsured are still unable to cover all their medical expenses. Some of the most common medical expenses that underinsured people are not able to cover include rising health care premiums, deductibles, and copayments, as well as limits on coverage for various services or other limits and excluded services that can increase out-of-pocket expenses.


  1. ^ a b c Preskitt, J; McEldowney; Mulvihill; Wingate; Menachemi (2012). "Underinsurance in children with special health care needs: Impact of definition on findings". Journal of Maternal and Child Health. 17: 1478–1487. doi:10.1007/s10995-012-1155-z.
  2. ^ Bethell,, Christina; Read; Blumberg; Newacheck (2008). "What is the Prevalence of Children with Special Health Care Needs? Toward an Understanding of Variations in Findings and Methods Across Three National Surveys". Journal of Maternal and Child Health. 12: 1–14. doi:10.1007/s10995-007-0220-5.
  3. ^ a b Magge, H.; Cabral; Kazis; Sommers (2013). "Prevalence and predictors of underinsurance among low-income adults". Journal of Internal Medicine. 28: 1136–1142. doi:10.1007/s11606-013-2354-z. PMC 3744314.
  4. ^ Bashshur, Rashid; Smith, Stiles (1993). "Defining Underinsurance: A conceptual Framework for Policy and Empirical Analysis". Journal of Medical Care Review.
  5. ^ "The Child and Adolescent Health Measurement Initiative (CAHMI)". Retrieved 2014-03-20.
  6. ^ "The Data Resource Center for Child and Adolescent Health". U.S. Department of Health and Human Services. Retrieved 2014-03-22.
  7. ^ Lee, Grace; Santoli; Hannan; Messonnier; Sabin; Rusinak; Gay; Lett; Lieu (2009). "Gaps in Vaccine Financing for Underinsured Children in the United States". Journal of the American Medical Association. 298: 638–643. doi:10.1001/jama.298.6.638. PMID 17684186.
  8. ^ "Advisory Committee for Immunization Practices (ACIP)". Center for Disease Control and Prevention. Retrieved 2014-03-22.
  9. ^ "Vaccines for Children's Program". Center for Disease Control and Prevention. Retrieved 2014-03-12.
  10. ^ "Rural Health Clinics" (PDF). Department of Health and Human Services. Retrieved 2014-03-18.
  11. ^ "Health Care Statistics in the United States". Health Care Problems. Retrieved 2014-03-28.