In 1996, only 66 percent of U.S. children younger than 18—47 million— were covered by private health insurance. Most private insurance for children is acquired through a parent’s employer. However, in 1993, almost one-fourth of the workforce worked for an employer that did not cover dependents. In addition, even if employers offer coverage, the amount that employees have to pay toward it for their families may make health insurance unaffordable. Since the late 1980s, workers’ costs for family coverage have risen sharply. Increases in insurance costs may affect children disproportionately, since the 71 million children younger than 18 represent 27 percent of the U.S. population but 42 percent of the poor. Even if children have insurance, their coverage—and their relationship with their providers—may be disrupted if their parents lose their jobs or change jobs frequently. Public health insurance for children is generally provided through the Medicaid program. Currently about 15.5 million (22 percent) of children younger than 18 are covered through Medicaid. The majority of low-income children (65 percent) in Medicaid have a working parent and, of those that do, about half have a parent working full time. To remain in Medicaid, families generally have their eligibility redetermined at least every 6 months. If family income or other circumstances change, children may go in and out of the Medicaid program during a year, disrupting their coverage. This can delay needed care, which can have long-term health consequences. Children are uninsured when they have neither public nor private coverage. In 1996, 10.6 million children (14.8 percent) were uninsured, living generally in lower-income working families. Compared with privately insured children, a higher proportion of their parents worked for small employers—the group least likely to offer health insurance. In 1993, only a quarter of employees in firms with fewer than 10 employees and about half in firms with 10 to 24 employees reported that their employer offered a health insurance plan for workers and their dependents, compared with 89 percent in firms with 1,000 or more employees. Health insurance does not always cover the preventive care, such as immunizations, that children need to develop optimally. Nevertheless, most of the studies we analyzed used many different measures of access and found that insured children were more likely to have access to both preventive and acute or chronic health care. Children who were insured were more likely to be connected to the health care system through a physician. Having a primary care connection made it easier for children to get regular preventive care, acute care when ill, and more complex care as needed. Uninsured and lower-income children were more likely to be hospitalized for conditions that could have been treated through primary care. Most of the studies we reviewed showed that children who had health insurance had better access to preventive and primary health care than uninsured children. (See table 1.) They were more likely to have a primary care provider, which increased their access to both routine and more complex care. Children who had private health insurance were also more likely than children who had no insurance to get medical care from one source, and that source was more likely to be in a physician’s office. In addition, they were more likely to have seen a doctor recently and to have been up to date with their well-child care. A child’s having a usual source of care increases the likelihood he or she will receive preventive or acute health care. One research study based on nationally representative data found that 20 percent of all uninsured children lacked a usual source of care, compared with 7 percent of insured, white, nonpoor children. Using regression analysis to isolate the effect of insurance from race, income, and ethnicity, this study found that uninsured children were twice as likely to lack a usual source of care as insured children. Uninsured children were also more likely to lack after-hours care and to spend more time traveling and more time waiting to receive care. Similarly, another study found that 33 percent of uninsured children did not go to a physician’s office for their routine care, compared with 14 percent of insured children (insured privately or through Medicaid). Controlling for factors other than insurance, the study found that uninsured children were more than twice as likely as insured children to get care in places other than a physician’s office. Generally, lower-income children (whether uninsured or receiving public insurance) are less likely to go to a physician’s office for their care. The National Center for Health Statistics (NCHS) found that 94 percent of U.S. children—more than 65 million—had a usual source of care in 1993. Of these, 94 percent of privately insured children, 62 percent of publicly insured children, and 74 percent of uninsured children used a doctor’s office as their usual source of care. Conversely, 5 percent of privately insured children, 30 percent of publicly insured children, and 20 percent of uninsured children used a clinic as their regular source of care. Most experts believe that preschool children need regular visits to physicians to stay current in their immunizations and to be screened for health problems, but researchers found access problems for preschool children. About one-quarter of U.S. 3-year-olds born in 1988 had a gap in their health insurance coverage of at least 1 month, and almost 15 percent had a gap of 7 months or more or had never been covered. Preschool children who had gaps in coverage were more likely to have gone to multiple sites for care than children who had continuous insurance coverage, suggesting that the care they received was more likely to be sporadic and fragmented. Just over 40 percent of preschool children went to two or more sites of care (not counting emergency care). However, controlling for other factors affecting access, preschool children who had a gap in coverage of more than 6 months were 74 percent more likely to have gone to more than one site for care. Disruption of insurance coverage seems to be the salient factor because children who had no insurance were no more likely than insured children to have gone to multiple sites of care. Experts have stated that adolescents can benefit from the guidance of a trusted health provider to help them through a period when their bodies are changing and they may be tempted to take risks, such as having unprotected sex or using drugs, alcohol, or tobacco products. Yet uninsured adolescents also have access problems. Researchers found that adolescents who were not insured were less likely to have a usual source of care and regular provider. (See fig. 1.) Better access to primary care is important, because primary care is a gateway to better preventive care and needed specialized services. A number of studies found that uninsured children had fewer health care and dental visits and fewer preventive visits. Compared with the parents of low-income children who had public insurance like Medicaid, parents of uninsured children of all income levels were more likely to defer bringing them into care for financial reasons. Having a primary care provider has been shown to improve care by facilitating the timely receipt of complex care. One study showed that children in Medicaid or who had no insurance were much less likely to have contacted a primary care physician before they came to the hospital with appendicitis. Children whose families did not contact a primary care physician before hospital admission were operated on less quickly if they were admitted on weekends and were more likely to have a perforated appendix. Contact with a primary care provider, not insurance status, was the key to differing rates of this complication, but having private insurance did increase the likelihood that a child would have a relationship with a primary care physician. Six studies that controlled for other factors affecting access found that uninsured children were less likely to receive routine checkups, dental care, or any kind of doctor’s visit. Some of them compared routine visits made with the number of visits recommended by the American Academy of Pediatrics (AAP) (see table 2) and found that uninsured children were less likely to meet such standards. For example, one study found that 30 percent of uninsured children were not up to date with well-child care visits, as AAP recommends, compared with 22 percent of insured children. Compared with insured children, and controlling for other factors that affect access, uninsured children were 50-percent more likely not to have made any visits to a physician in the past year and almost twice as likely never to have had routine care. In a local California study, lack of insurance was the strongest predictor that children older than 5 had not seen a dentist in the past year, compared with privately insured children. Uninsured children were less likely to have received care when it was not an emergency. An analysis of the 1980 National Medical Care Utilization and Expenditure Survey, after adjusting for other factors affecting access, found that uninsured children had a 69-percent likelihood that they would use nonemergency ambulatory care during the year, compared with 81 percent for privately insured children. The uninsured children who had used health services had made fewer nonemergency ambulatory visits, compared with privately insured children. (See fig. 2.) Similarly, an analysis of a more recent survey also showed that being uninsured was a significant predictor of not using a physician’s services. Several studies found that uninsured children were not getting care for conditions that could be serious. Children who had no insurance had lower rates of treatment for injuries, including serious injuries such as broken bones or cuts requiring stitches, compared with children who had private insurance, and were less likely to get care when sick. Sometimes they received care later, after they had become sicker. Childhood injuries were fairly common, but insurance status affected a child’s chances of being medically treated for an injury. In 1988, children younger than 18 had total injury rates of 16.3 per 100. Serious injuries that resulted in restricted activity, bed days, surgery, hospitalization, or substantial pain represented about half of total injuries. A study that compared injury treatment for insured children (private insurance and Medicaid combined) and uninsured children found that the uninsured were less likely to be brought in for the treatment of injuries.