Many Americans view health care for their children and themselves as one of their top concerns. The adverse consequences of going without health insurance may include unmet health and dental needs, lower receipt of preventive services, avoidable hospitalizations, increased likelihood of receiving expensive emergency room care, and reduced likelihood that the doctor is familiar with the patient's medical history. From a public health perspective, early and frequent monitoring of children's health is a key component to ensuring the appropriate growth and development of children. From a family perspective, health insurance coverage can reduce parental financial and emotional stress. Child support is the cash payment that noncustodial parents are obligated to pay to custodial parents for the financial support of their children. Child support payments enable parents who do not live with their children to fulfill their financial obligation to their children by contributing to the payment of childrearing costs. Ensuring that children get health care is one of the basic responsibilities of the Child Support Enforcement (CSE) program. Operating under federal and state statutes and regulations, state and local child support agencies are required to ensure that health care costs, generally referred to as medical support, are included in every child support order. These costs may include payment of medical, dental, prescription and other health care expenses for children and provisions to cover health insurance costs as well as cash payments for unreimbursed medical expenses. State child support guidelines, as well as state law and guidance, operationalize what constitutes medical support in a particular state. This broad definition of medical support is relatively recent. Originally, federal requirements for child support orders focused on reimbursement for Medicaid expenses and employer-related health insurance available to the noncustodial parent. Beginning in 1977, Congress has tried to offset some of the state costs associated with the Medicaid program (Title XIX of the Social Security Act) by allowing states to require Medicaid recipients to assign their child support rights to the state and allowing the state to pursue private health insurance coverage and/or noncustodial parents for reimbursement of the cost of Medicaid benefits provided to the child. The underlying assumption was that children enrolled in public health coverage (i.e., Medicaid) might obtain employer-based coverage (to offset the cost of Medicaid) through the noncustodial parent. Beginning in 1984, mandatory assignment became law. In 1984, federal law required that state CSE agencies petition for the inclusion of medical support as part of any child support order whenever health care coverage was available to the noncustodial parent at reasonable cost. A 1993 amendment to the Employee Retirement Income Security Act (ERISA) required employer-sponsored group health plans to extend health care coverage to the children of a parent/employee who is divorced, separated, or never married when ordered to do so by the state CSE agency via a Qualified Medical Child Support Order (QMCSO). The 1996 welfare reform law further strengthened medical support by stipulating that all orders enforced by the state CSE agency must include a provision for health care coverage. The 1996 law also directed the CSE agency to notify the noncustodial parent's employer of the employee's medical child support obligation. To help obtain health care coverage for children, a 1998 law authorized the creation of the National Medical Support Notice (NMSN), a standardized form that is the exclusive document which must be used by all state CSE agencies. An appropriately completed NMSN is considered to be a "Qualified Medical Child Support Order," and as such must be honored by the noncustodial parent's group health plan. This legislation also required the establishment of a Medical Support Working Group to make further recommendations to the Secretaries of Labor and Health and Human Services on how to improve medical support and to submit those recommendations to Congress. As evidenced in this brief history, since 1984, Congress has tried to increase provision of private health care coverage for children whose noncustodial parent has access to employer-based or group health insurance that is provided at a reasonable cost. This strategy was seen as a way to make noncustodial parents responsible for their children and lessen taxpayer burden by shifting the cost of providing health care to children from the taxpayers back to the noncustodial parents. For a detailed legislative history of provisions related to medical child support, see Appendix A . In 2006, federal law defined the term "medical support" and required that states have procedures under which all child support orders that are enforced by CSE agencies must include a provision for medical support for the child to be provided by either or both parents. Federal law further stipulated that CSE agencies may enforce medical support against a custodial parent if health care coverage is available to the custodial parent at a reasonable cost. Medical support adds complexity to the CSE program, in part, because the provision of medical child support can be imposed on either the noncustodial parent, the custodial parent, or both parents. Medical child support may be a significant additional expense for noncustodial parents. In addition to the child support payment, noncustodial parents may be legally liable for paying health insurance premium costs, co-payments, deductibles, and/or unreimbursed medical expenses. High health insurance premiums may negatively impact how much disposable income the noncustodial parent has available to meet his or her financial child support order. If the premium is high, cash support may be substantially reduced, leaving the custodial parent without enough money to take care of the child's food, clothing, and shelter needs. Health care coverage of children and medical child support are not synonymous. A child could be covered by a custodial parent's health insurance plan and the child support order may not contain any provision for medical support from the noncustodial parent. Conversely, a child may be receiving cash medical support but not be insured. Based on information from the federal Office of Child Support Enforcement (OCSE) in the Department of Health and Human Services (HHS), in the future, the establishment and enforcement of medical child support may become a CSE program performance measure, however, more needs to be done before that can occur. Thus, even though states submit medical support data, the information is not subject to an audit to determine if it is "complete and reliable." Also, because medical support establishment allows states to initiate legal medical support orders before determining whether or not the health insurance is affordable/reasonable, state CSE agencies are severely hampered, if not totally stymied, in successfully enforcing medical child support orders. Data from OCSE indicate that there has been some improvement in the establishment of medical child support but considerably less improvement in the enforcement of medical child support. According to OCSE data, in FY2011, 81% of child support cases that had a child support order included medical child support. In comparison, in FY1995, 61% of child support cases that had a child support order included medical child support. In contrast, the enforcement of medical support orders continues to be problematic. In FY2011, the medical support order was complied with in only 33% of the cases in which medical support had been ordered. (See Appendix B.) The comparable figure in FY1995 was the same, 33%. The CSE program has at its disposal a wide variety of methods by which to obtain child support obligations. Collection methods used by state CSE agencies include income withholding, intercept of federal and state income tax refunds, intercept of unemployment compensation, liens against property, reporting child support obligations to credit bureaus, intercept of lottery winnings, sending insurance settlement information to CSE agencies, authority to withhold or suspend driver's licenses, professional licenses, and recreational and sporting licenses of persons who owe past-due support, authority to seize assets of debtor parents held by public or private retirement funds and financial institutions, and authority for the Secretary of State to deny, revoke, or restrict passports of debtor parents. Also included in their available methods to collect child support obligations, states use the threat of jail and actual incarceration. Efforts to improve the establishment and enforcement of medical child support have a better chance of success if analyzed in the context of factors such as high health care costs, a decline in employer-provided health insurance coverage, an increase in the share of health insurance costs borne by employees, and a significant number of noncustodial parents who have low or moderate incomes. Moreover, it is important to recognize, as mentioned earlier, that cash support and medical support are not always compatible. For example, if premiums, co-payments, and deductibles for health insurance and medical care owed by noncustodial parents rise, equity might suggest that the cash child support payment of noncustodial parents be reduced to reflect their payment of these medical costs. Custodial parents may then have less income to provide for the basic food, clothing, and shelter needs of their children. Conversely, if medical child support is not available, the family would be more likely to be financially disadvantaged by routine health care needs of children and could face dire economic circumstances if a child becomes seriously ill. However, it must be recognized that there is a lot of overlap between cash support and medical support. According to some CSE administrators, a primary reason for upward modifications of child support awards is care needed for a child with special needs. Many states combine any cash medical support payment to the custodial parent with the regular child support order as a single payment. Some states order that the parents will split all medical costs leaving it to the parents to work it out between themselves. Additionally some experts argue that routine medical expenses, including health insurance costs, are in fact rolled into the expenditures data used to calculate the cost of raising a child upon which child support guidelines are based. The public and policymakers generally agree that establishment and enforcement of medical support promotes equity in allocating childrearing costs between custodial and noncustodial parents, and usually saves federal and state dollars.