health care costs, employers have been shifting a greater proportion of the costs of dependent coverage to their employees. Many working parents have low-wage jobs with small businesses that do not pay for their insurance coverage, and there are very few affordable insurance products for dependent coverage in the individual insurance market.

The declining rates in employer-based coverage have been partially offset by increases in Medicaid enrollment. Due to changes associated with welfare reform, however, Medicaid enrollment may begin to decrease. If these trends continue, the number of uninsured children is likely to continue to increase.

More than 11 million American children are uninsured. Most uninsured children live in families with working parents. Many are not eligible for Medicaid because their parents tend to work in low-wage jobs for employers that do not offer health insurance, and the parents cannot afford to purchase private insurance on their own. More than 3 million children nationally are eligible for Medicaid but are not enrolled for a variety of reasons.

Black and Hispanic children are more likely than white children to lack coverage. Nationally, one out of every six black children and one out of every four Hispanic children are uninsured, and one out of ten white children is uninsured.

State and regional variations in coverage rates are significant, in part because of differences in Medicaid coverage options for children used by each state, differences in state-sponsored programs and private initiatives, and also because of state and regional economic differences. Under the new SCHIP program, some of these coverage patterns will begin to change.

Health Insurance And Access To Care

After reviewing evidence about financial and nonfinancial barriers to health care access, the committee has determined that insurance coverage is the major determinant of whether children have access to health care. This determination is based on the finding that is consistent across many studies: compared with children who have insurance coverage, uninsured children have many unmet health care needs. They are more likely to be sick as newborns, less likely to be immunized as preschoolers, less likely to receive medical treatment when they are injured, and less likely to receive treatment for illnesses such as acute or recurrent ear infections, asthma, and tooth decay.

Access to health care can influence children's physical and emotional growth, development, and overall health and well-being. Untreated illnesses and injuries can have long-term—even lifelong—consequences. For example, untreated ear infections can lead to hearing loss or deafness. Children who are unable to hear well can have trouble performing well in school and trouble interacting normally with their families and friends. Language or other developmental delays due to untreated neurological problems also can frustrate normal development and social interactions.

Uninsured children are the least likely members of society to have routine access to a physician. Without a regular source of care, low-income children are more likely to use publicly funded clinics for standard preventive services such as immunizations and are more likely to use emergency rooms for care for acute illnesses. Some aspects of the health care system also can create barriers to access, particularly the shortages of providers to serve low-income groups, lack of cultural sensitivity, and inconvenient scheduling.

Although children who are uninsured have less access to care, the presence of insurance alone will not eliminate all of the barriers to accessing appropriate health care services. Children are dependent on their parents to identify problems and seek treatment, and even insured and responsible parents may delay seeking care because of the cost of the out-of-pocket expenses or because it is difficult or inconvenient to schedule appointments. Delays in ambulatory care because of cost may result in diagnosis or treatment later in the course of illness or disease, when treatment may be more complex and more expensive.

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