For the school year 1998- 1999, the National Federation of State High School Associations (NFHS) reported that there were about 11.8 million public high school students in the 50 states and the District of Columbia. School-based sports programs include about 6.5 million participants in more than 17,850 high schools across the nation. Of the total number of participants, 3.8 million were boys and 2.7 million were girls. As would be expected, large states have high numbers of student athletes. Texas, for example, had the greatest number of participants with 783,751 high school athletes, followed by California with 584,590 athletes. Among individual sports, basketball is the most popular high school sport, with 16,763 programs for boys and 16,439 programs for girls. In terms of individual participants, football is the most popular boys’ sport with 983,625 participants. Basketball is the most popular girls’ sport, with 456,873 students playing on high school teams. Athletic injuries among high school athletes are common. A 1999 study conducted for the National Athletic Trainers Association estimates that the national student athlete population experiences more than 2 million injuries of varying degree per year, around 500,000 doctor visits, and 30,000 hospitalizations. The study recorded injury data collected on 10 sports from a national sample of high schools and found that football was associated with the greatest number of injuries and involved the highest likelihood that some type of injury would occur. Furthermore, of all injuries recorded for all sports, 56 percent occurred during practice and 74 percent restricted the student athlete from participating in a sports program for fewer than 8 days. Another ongoing study conducted by the National Center for Catastrophic Sports Injury Research examined serious and fatal injuries suffered by high school sports participants from 1982 through 1998. During this period, football players suffered 67 fatalities, 161 nonfatal injuries, and 175 serious injuries.With the exception of these studies, national injury data are not routinely collected, maintained, or published. To help address the health insurance needs of low-income children, which could include those participating in high school sports, the Congress established the State Children’s Health Insurance Program (SCHIP).From fiscal year 1998 to fiscal year 2008, this program will provide more than $40 billion to states for the child health system under the federal/state Medicaid program or other state-established health insurance programs. The Department of Health and Human Services distributes the funds to states based on a formula that includes the state’s number of low-income children, the state’s number of uninsured low-income children, and the state’s health care costs as compared with other states. States are afforded a significant level of flexibility in defining the groups of children targeted for coverage under the new program. Specifically, under SCHIP, states choose to spend the new funds by (1) expanding Medicaid and building on the existing program; (2) establishing a separate, stand-alone program; or (3) combining these two approaches. The program targets funds at uninsured children in families whose income is too high to qualify for Medicaid but is at or below 200 percent of the federal poverty level, that is, $32,900 for a family of four. States also have discretion as to how to calculate income (gross, net, or countable income). More significantly, states have flexibility in establishing nonfinancial eligibility criteria. For example, SCHIP can use criteria such as residency, geographic area, and access to other health coverage. About 2 million children have been enrolled to date, but it remains uncertain the extent to which additional children will enroll in SCHIP. Of the 13 million children without basic health insurance, more than 3 million are of high school age (14- 18).Substantial differences in the uninsured rate among children of high school age exist across states. For example, the estimated uninsured rates among the states we either visited or contacted range from a high of 27.9 percent in Texas to a low of 5.7 percent in Massachusetts (see fig. 1 for uninsured rates among large states). The extent to which any of these children are prevented from participating in high school sports is unknown. We found no systematic data collection efforts or single data sources that document the number of high school students prohibited from participating in school-based sports due to the lack of insurance. In our survey of high school athletic associations, officials were unaware of any instance in which a high school student was prohibited from playing high school sports due to a lack of health insurance. Some states and school districts require high school student athletes to have basic health insurance prior to and while participating in a sports program. Our survey of high school athletic association officials found that only 10 states and the District of Columbia have a statewide requirement that student athletes have health insurance to participate in a sports program. However, according to officials of high school athletic associations, many school districts require health insurance for athletes. Of the 18 school districts we reviewed, 17 required that their student athletes have basic insurance to participate in high school sports.Within some of these districts, school officials we spoke to stated that athletic staff at each school collect information about the status of each student athlete’s private insurance. For example, Fairfax County District Schools in Virginia collect insurance information as part of establishing the eligibility of student athletes, which generally includes a physical examination and a signed parental consent form. We found, however, that local schools often do not verify health insurance information before students participate in sports, nor do they follow up on this during the school year. High school officials in many of the 18 districts reviewed pointed out that this information is usually collected only once during the school year and that schools are unable to verify the accuracy of the data collected due to time and expense. Further, an expert on uninsured populations noted that it is not unusual for students to lose their insurance coverage at some point during the school year due to a change in their parent’s job status. For example, an athlete’s parent may lose his or her job at some point during the school year, resulting in lost insurance benefits for the child. In addition, several school and health care officials we spoke to suggested that it is not uncommon for students or parents to misrepresent their current insurance status so that the student can participate in a school’s sports program. School districts and health care organizations in the locations we visited have developed strategies to make athletic accident insurance available to student athletes and to provide access to athletic accident-related care. Most school districts provided catastrophic athletic accident insurance to all student athletes regardless of their insurance status and also offered health insurance to student athletes free of charge or at low cost. School district officials reported that both the school district and local community organizations addressed instances of uninsured students who required care due to athletic accidents. In addition, in all 18 school districts we reviewed, including hospitals, medical centers, and sports assisted local school districts by offering free medical services to student athletes. Sixteen of the 18 school districts we reviewed offered free catastrophic coverage to high school athletes. The other two school districts are self- insured for catastrophic situations. Catastrophic injury insurance is meant to cover the medical costs for serious injury, such as a fractured vertebra or paralysis. In most of the school districts we contacted, this insurance coverage commences when the athlete’s medical bills reach $25,000. The maximum amount of coverage ranges from $1 million to $5 million depending on the district. School officials we spoke to stated that catastrophic injuries within their districts are rare but that catastrophic insurance is nonetheless important. For example, one school official from the El Paso Independent School District in Texas said that one student had experienced head trauma in a football game and had been hospitalized for 6 months. The school districts we visited emphasized that the premiums they pay for catastrophic insurance are relatively low. For example, the Austin Independent School District in Texas pays approximately $13,000 to provide catastrophic insurance coverage to all 10,000 students participating in school sports. In addition to catastrophic injury insurance, 17 of the 18 school districts we reviewed either provide free supplemental athletic accident insurance to student athletes or offer athletic accident insurance to student athletes for a fee. Eight of the public school districts we contacted purchased supplemental athletic accident insurance for their student athletes. These plans are blanket policies purchased for a specific number of student athletes at a set rate. For example, the San Antonio Independent Schools in Texas pay approximately $260,000 to cover about 17,000 sports participants. Other examples of similar strategies are in effect across the nation. The El Paso Independent School District in Texas insures all high school athletes at no charge to the student. The policy provides secondary insurance coverage to most student athletes and acts as a primary plan for student athletes who are injured during a sports activity and do not have other insurance coverage. The District of Columbia insures high school students participating in sports at no charge to the student. Although the policy has a $100 deductible should the student athlete file a claim for needed care, very seldom is the deductible fee charged for low-income students. The Indianapolis School District in Indiana provides for and pays the insurance premiums for high school students participating in sports. The policy is intended to be a supplemental policy. However, if a student does not have basic health insurance coverage, the school policy becomes the primary insurance if the student is injured during athletics. App. II presents an example of a supplemental athletic accident coverage plan that is provided to student athletes’ parents or guardians. Nine school districts we reviewed offer students the opportunity to purchase low-cost athletic accident insurance. In these districts, the student athlete may purchase an athletic accident policy through the school. These policies cover only accidents occurring during authorized events such as games or formal practices. App. III, provided by Fairfax County School District of Virginia, is an example of such a policy. While most of the districts that offer these accident policies require them only when the student athlete does not have insurance, some school districts require that all student athletes—regardless of insurance status— purchase a policy through the district.