The Effect of Parental Immigration Authorization on Health Insurance Coverage for Migrant Latino Children

Objective: To examine if immigration authorization among parents is associated with health insurance coverage for migrant Latino children. Data Source: A cross-sectional household survey of 300 migrant families for which one child, aged <13 years, was randomly selected. Results: Most children lacked insurance (73%) and had unauthorized parents (77%). Having an authorized parent or parental stay of more than 5 years in the US were each positively associated with children’s health insurance coverage [OR: 4.9; 95% CI: (2.7–8.7) and [OR = 6.7; 95% CI: (3.8–12.0), respectively]. The effect of parental authorization did not persist in multivariable logistic regression analysis; however, more than 5 years of parental stay in the US remained associated with children’s insurance coverage [OR = 4.8; 95% CI (1.8–12.2)], regardless of parental authorization. Conclusion: Increased parental familiarity with US health and/or social services agencies, rather than parental authorization status, is important to obtaining health insurance for migrant children. Efforts to insure eligible migrant children should focus on recently arrived families.     

Children’s Receipt of Health Care Services and Family Health Insurance Patterns

PURPOSE Insured children in the United States have better access to health care services; less is known about how parental coverage affects children’s access to care. We examined the association between parent-child health insurance coverage patterns and children’s access to health care and preventive counseling services.METHODS We conducted secondary analyses of nationally representative, cross-sectional, pooled 2002–2006 data from children (n = 43,509), aged 2 to 17 years, in households responding to the Medical Expenditure Panel Survey (MEPS). We assessed 9 outcome measures pertaining to children’s unmet health care and preventive counseling needs.RESULTS Cross-sectionally, among US children (aged 2 to 17 years) living with at least 1 parent, 73.6% were insured with insured parents, 8.0% were uninsured with uninsured parents, and the remaining 18.4% had discordant family insurance coverage patterns. In multivariable analyses, insured children with uninsured parents had higher odds of an insurance coverage gap (odds ratio [OR] = 2.45; 95% confidence interval [CI], 2.02–2.97), no usual source of care (OR = 1.31; 95% CI, 1.10–1.56), unmet health care needs (OR = 1.11; 95% CI, 1.01–1.22), and having never received at least 1 preventive counseling service (OR = 1.20; 95% CI, 1.04–1.39) when compared with insured children with insured parents. Insured children with mixed parental insurance coverage had similar vulnerabilities.CONCLUSIONS Uninsured children had the highest rates of unmet needs overall, with fewer differences based on parental insurance status. For insured children, having uninsured parents was associated with higher odds of going without necessary services when compared with having insured parents.     

The State Children's Health Insurance Program: a multicenter trial of outreach through the emergency department

OBJECTIVES: We evaluated emergency department (ED)-based outreach for the State Children's Health Insurance Program (SCHIP). METHODS: We conducted a multicenter trial among uninsured children (< or = 18 years) who presented to 5 EDs in 2001 and 2002. On-site staff enrolled consecutive subjects for a control period followed by an intervention period during which staff handed out SCHIP applications to the uninsured. The primary outcome was state-level confirmation of insured status at 90 days. RESULTS: We followed 223 subjects (108 control, 115 intervention) by both phone interview and state records. Compared to control subjects, those receiving a SCHIP application were more likely to have state health insurance at 90 days (42% vs 28%; P<.05; odds ratio [OR]=3.8; 95% confidence interval [CI]=1.7, 8.6). Although the intervention effect was prominent among 118 African Americans (50% insured after intervention vs 31% of controls, P<.05), lack of family enrollment in other public assistance programs was the primary predictor of intervention success (OR=3.7; 95% CI=1.6, 8.4). CONCLUSIONS: Handing out insurance applications in the ED can be an effective SCHIP enrollment strategy, particularly among minority children without connections to the social welfare system. Adopted nationwide, this simple strategy could initiate insurance coverage for more than a quarter million additional children each year.     

Characteristics of children eligible for public health insurance but uninsured: data from the 2007 National Survey of Children's Health

To describe the state variation, demographic and family characteristics of children eligible for public health insurance but uninsured. Using data from the National Survey of Children's Health we selected a subset of children living in households with incomes <200 % of the federal poverty level, who are generally eligible for Medicaid or CHIP. We used multiple logistic regression to examine associations between insurance status among this group of eligible children and certain demographic factors, family characteristics, and state of residence. In adjusted models children aged 6-11 and 12-17 years were more likely to be eligible but uninsured compared to those aged 0-5 years (AOR 1.57; 95 % CI 1.15-2.16 and AOR 1.93; 95 % CI 1.41-2.64). Children who received school lunch (AOR 0.67; 95 % CI 0.52-0.86) and SNAP (AOR 0.33; 95 % CI 0.24-0.46) were less likely to be eligible but uninsured compared to those children not receiving those needs based services; however, a majority (58.7 %) of eligible uninsured children were enrolled in the school lunch program. Five states (Texas, California, Florida, Georgia, New York) accounted for 46 % of the eligible uninsured children. Vermont had the lowest adjusted estimate of eligible uninsured children (3.6 %) and Nevada had the highest adjusted estimate (35.5 %). Using nationally representative data we have identified specific state differences, demographic and household characteristics that could help guide federal and local initiatives to improve public health insurance enrollment for children who are eligible but uninsured.     

Continuity of Health Insurance Coverage for Children with Special Health Care Needs

Objectives: To assess the continuity of health insurance coverage and its associated factors for children with special health care needs (CSHCN). Methods: Logistic regression and proportional hazard models were estimated on monthly insurance enrollment for 5594 children in the 1996 Medical Expenditure Panel Survey. CSHCN were identified using a non-categorical approach. Stratified analyses were conducted to determine whether any characteristics differentiated the effects of CSHCN status on children's coverage. Results: In 1996, more than 8% of CSHCN were uninsured for the entire year. For those who were insured in January 1996, 14% lost their coverage by December 1996. CSHCN were more likely than other children to be insured (92% vs. 89%), mainly due to their better access to public insurance (35% vs. 23%). Conversely, CSHCN were less likely than other children to stay insured if they were school-aged, non-Hispanic White, from working, low-income families or the US Midwest region. Higher parental education improved health insurance enrollment for CSHCN, whereas higher family income or having activity limitations protected them from losing coverage. Regardless of CSHCN status, being publicly insured was associated with a higher risk of losing coverage for children. Conclusions: Despite increased health care needs, a considerable proportion of CSHCN is unable to access or maintain coverage. Compared to other children, CSHCN are more likely to have coverage but no more likely to stay insured. Improving continuity of coverage for publicly insured children is needed, especially CSHCN who are more likely to obtain their coverage through public programs.     

The uninsured and the affordability of health insurance coverage

The 2005 Current Population Survey (CPS) is used to estimate what share of uninsured Americans are eligible for coverage through Medicaid or the State Children's Health Insurance Program (SCHIP), need financial assistance to purchase health insurance, and are likely able to afford insurance. Twenty-five percent are eligible for public coverage, 56 percent need assistance, and 20 percent can afford coverage. This varies across uninsured populations: 74 percent of children are eligible for public programs, and 57 percent and 69 percent of parents and childless adults, respectively, need assistance. A central conclusion is that a large percentage of uninsured adults need help purchasing health insurance.     

Acutely injured patients with trauma in Massachusetts: differences in care and mortality, by insurance status.

OBJECTIVES. This study was designed to determine whether resource use and mortality differed by insurance status for patients with acute trauma. METHODS. All adults emergently hospitalized in Massachusetts during 1990 with acute trauma (n = 15,008) were examined. RESULTS. After adjustment for confounders, uninsured patients were as likely to receive care in an intensive care unit as were patients with private insurance (odds ratio [OR] = 0.97, 95% confidence interval [CI] = 0.85, 1.11) but were less likely to undergo an operative procedure (OR = 0.68, 95% CI = 0.63, 0.74) or physical therapy (OR = 0.61, 95% CI = 0.57,0.67) and were more likely to die in a hospital (OR = 2.15, 95% CI = 1.44, 3.19). Compared with patients with private insurance, those with Medicaid were less likely to receive an operative procedure (0.85, 0.75-0.97), were equally likely to receive care in an intensive care unit (OR = 1.05, 95% CI = 0.86, 1.30) or physical therapy (OR = 0.90, 95% CI = 0.79, 1.02), and were no more likely to die (OR = 1.28, 95% CI = 0.69,2.39). CONCLUSIONS. These results suggest that the uninsured receive less trauma-related care and have a higher mortality rate. The excess mortality in uninsured patients may be avoided if their resource use is increased to that of insured patients.     

Characteristics of Children Eligible for Public Health Insurance but Uninsured: Data from the 2007 National Survey of Children’s Health

To describe the state variation, demographic and family characteristics of children eligible for public health insurance but uninsured. Using data from the National Survey of Children’s Health we selected a subset of children living in households with incomes <200 % of the federal poverty level, who are generally eligible for Medicaid or CHIP. We used multiple logistic regression to examine associations between insurance status among this group of eligible children and certain demographic factors, family characteristics, and state of residence. In adjusted models children aged 6–11 and 12–17 years were more likely to be eligible but uninsured compared to those aged 0–5 years (AOR 1.57; 95 % CI 1.15–2.16 and AOR 1.93; 95 % CI 1.41–2.64). Children who received school lunch (AOR 0.67; 95 % CI 0.52–0.86) and SNAP (AOR 0.33; 95 % CI 0.24–0.46) were less likely to be eligible but uninsured compared to those children not receiving those needs based services; however, a majority (58.7 %) of eligible uninsured children were enrolled in the school lunch program. Five states (Texas, California, Florida, Georgia, New York) accounted for 46 % of the eligible uninsured children. Vermont had the lowest adjusted estimate of eligible uninsured children (3.6 %) and Nevada had the highest adjusted estimate (35.5 %). Using nationally representative data we have identified specific state differences, demographic and household characteristics that could help guide federal and local initiatives to improve public health insurance enrollment for children who are eligible but uninsured.     

Is Health Insurance Enough? A Usual Source of Care may be More Important to Ensure a Child Receives Preventive Health Counseling

Despite the promise of expanded health insurance coverage for children in the United States, a usual source of care (USC) may have a bigger impact on a child’s receipt of preventive health counseling. We examined the effects of insurance versus USC on receipt of education and counseling regarding prevention of childhood injuries and disease. We conducted secondary analyses of 2002–2006 data from a nationally-representative sample of child participants (≤17 years) in the Medical Expenditure Panel Survey (n = 49,947). Children with both insurance and a USC had the lowest rates of missed counseling, and children with neither one had the highest rates. Children with only insurance were more likely than those with only a USC to have never received preventive health counseling from a health care provider regarding healthy eating (aRR 1.21, 95% CI 1.12–1.31); regular exercise (aRR 1.06, 95% CI 1.01–1.12), use of car safety devices (aRR 1.10, 95% CI 1.03–1.17), use of bicycle helmets (aRR 1.11, 95% CI 1.05–1.18), and risks of second hand smoke exposure (aRR 1.12, 95% CI 1.04–1.20). A USC may play an equally or more important role than insurance in improving access to health education and counseling for children. To better meet preventive counseling needs of children, a robust primary care workforce and improved delivery of care in medical homes must accompany expansions in insurance coverage.     

Impact of health insurance status on vaccination coverage in children 19-35 months old, United States, 1993-1996

OBJECTIVES: To show how health insurance (privately and publicly insured, insured and uninsured) relates to vaccination coverage in children 19-35 months old, and how this can be used to better target public health interventions. METHODS: The National Health Interview Survey (NHIS) gathers information on the health and health care of the U.S. non-institutionalized population through household interviews. The authors combined immunization and health insurance supplements from the 1993 through 1996 NHIS, and classified children 19-35 months old by their immunization and insurance status. Results were compared using both bivariate and multivariate analyses, and the backwards stepwise selection method was used to build multivariate logistic regression models. RESULTS: Uninsured children tended to have lower vaccination coverage than those who had insurance, either private or public. Among those with insurance, publicly insured children had lower vaccination coverage than privately insured children. Backwards stepwise regression retained insurance status, metropolitan statistical area, and education of responsible adult family member as major predictors of immunization. Factors considered but not retained in the final model included child race/ethnicity, family poverty index, and region of country. CONCLUSIONS: Insurance status was a critical predictor of vaccination coverage for children ages 19-35 months. After controlling for confounders, the uninsured were about 24% less likely to receive all recommended shots than the insured and, among the insured, those with public insurance were about 24% less likely to receive all recommended vaccines than those with private insurance.     

Recent Health Insurance Trends for US Families: Children Gain While Parents Lose

In the past decade, political and economic changes in the United States (US) have affected health insurance coverage for children and their parents. Most likely these policies have differentially affected coverage patterns for children (versus parents) and for low-income (versus high-income) families. We aimed to examine—qualitatively and quantitatively—the impact of changing health insurance coverage on US families. Primary data from interviews with Oregon families (2008–2010) were analyzed using an iterative process. Qualitative findings guided quantitative analyses of secondary data from the nationally-representative Medical Expenditure Panel Survey (MEPS) (1998–2009); we used Joinpoint Regression to assess average annual percent changes (AAPC) in health insurance trends, examining child and parent status and type of coverage stratified by income. Interviewees reported that although children gained coverage, parents lost coverage. MEPS analyses confirmed this trend; the percentage of children uninsured all year decreased from 9.6 % in 1998 to 6.1 % in 2009; AAPC = ?3.1 % (95 % confidence interval [CI] from ?5.1 to ?1.0), while the percentage of parents uninsured all year rose from 13.6 % in 1998 to 17.1 % in 2009, AAPC = 2.7 % (95 % CI 1.8–3.7). Low-income families experienced the most significant changes in coverage. Between 1998 and 2009, as US children gained health insurance, their parents lost coverage. Children’s health is adversely affected when parents are uninsured. Investigation beyond children’s coverage rates is needed to understand how health insurance policies and changing health insurance coverage trends are impacting children’s health.     

Association between health insurance coverage and uptake of seasonal influenza vaccine in Brazos County,Texas

BackgroundLack of health insurance may limit access to influenza vaccination, resulting in higher risk of infection.MethodsThe Brazos County Health Department obtained medical records summarizing vaccination and health insurance status of all influenza cases occurring in December 2017 (n = 417). The odds of influenza vaccination were estimated for those with public or private health insurance as compared to uninsured individuals using multivariate logistic regression analysis adjusted for age and race.ResultsHealth insurance coverage among Brazos County residents with influenza was 62.4%. Public and private health insurance was associated with higher odds of influenza vaccination compared to no insurance (aOR: 2.05; 95% CI: 1.00–4.21 and aOR: 1.77; 95% CI: 1.07–2.92, respectively), particularly among adults 18–64 years of age.ConclusionsInfluenza vaccination is strongly associated with health insurance. Expansion of programs that facilitate access to health services or provide free influenza vaccines may improve influenza prevention among the uninsured.     

No care for the caregivers: declining health insurance coverage for health care personnel and their children, 1988-1998

OBJECTIVES: This study examined trends in health insurance coverage for health care workers and their children between 1988 and 1998. METHODS: We analyzed data from the annual March supplements of the Current Population Survey (CPS), a Census Bureau survey that collects information about health insurance from a nationally representative sample of noninstitutionalized US residents. RESULTS: Of the health care personnel younger than 65 years, 1.36 million (90% confidence interval [CI] = 1.28 million, 1.45 million) were uninsured in 1998, up 83.4% from 1988; the proportion uninsured rose from 8.4% (90% CI = 7.8%, 9.1%) to 12.2% (90% CI = 11.5%, 12.9%). Declining coverage rates in the growing private-sector health care workforce---and declining health employment in the public sector, which provided health insurance benefits to more of its workers---accounted for the increases. Households with a health care worker included 1.12 million (90% CI = 1.05 million, 1.20 million) uninsured children, accounting for 10.1% (90% CI = 9.5%, 10.8%) of all uninsured children in the United States. CONCLUSIONS: Health care personnel are losing health insurance coverage more rapidly than are other workers. Increasingly, the health care sector is consigning its own workers and their children to the ranks of the uninsured.     

Patterns of Health Insurance Discontinuity and Children’s Access to Health Care

Objectives This study classified patterns of discontinuous health insurance coverage, including change in coverage type and gaps in coverage, and described their associations with children’s access to health care. Methods Using the 2011–2013 National Health Interview Survey data, we determined children’s insurance coverage over the past year, and whether children had a usual source of care, had to delay getting care, or had unmet health care needs. Using multivariable logistic regression, we compared measures of access to care across insurance coverage patterns, classified as continuous private coverage; continuous public coverage; continuous lack of coverage; change in coverage type (public versus private) without gaps in coverage; and any gap in coverage. A subgroup analysis repeated this comparison for children with a caregiver-reported chronic physical illness. Results The analysis included 34,105 children, of whom 7% had a gap in coverage and 1% had a change in coverage type. On multivariable analysis, gaps in coverage were associated with increased likelihood of unmet health care needs, compared to continuous private (OR 6.9; 95% CI 5.9, 8.0) or continuous public coverage (OR 5.1; 95% CI 4.4, 6.0). Seamless changes in coverage were also associated with greater likelihood of unmet health care needs [OR vs. private: 3.8 (95% CI 2.3, 6.1); OR vs. public: 2.8 (95% CI 1.8, 4.6); all p < 0.001]. Results were similar for other study outcomes, and among children with chronic physical illness. Conclusions for Practice Both gaps in coverage and seamless changes between coverage types were associated with limited health care access for children.

     

Covering kids: variation in health insurance coverage trends by state, 1996-2002

We estimated state-specific changes in health insurance coverage rates for children between 1996-1998 and 2001-2002. We found considerable variation in the changing distribution of health insurance coverage for children across states, with significant increases in public program coverage in twenty-nine states and significant decreases in uninsured children in twenty-seven. Children in families with incomes below 200 percent of the federal poverty level were the most likely to enroll in public programs. We provide an overview of state outreach and administrative simplification efforts and raise concerns about the persistent variation in children's health insurance coverage across states.     

Immigrant children's reliance on public health insurance in the wake of immigration reform

Objectives. We sought to determine whether the reversal of the public charge rule of the Illegal Immigration Reform and Immigrant Responsibility Act, which may have required families to pay for benefits previously received at no cost, led to immigrant children becoming increasingly reliant on public health insurance programs.Methods. We conducted a secondary data analysis focusing on low-income children sampled in the 1997 through 2004 versions of the National Health Interview Survey.Results. Between 1997 and 2004, public health insurance enrollments and the numbers of uninsured foreign-born children in the United States increased by 3.1% and 2.7%, respectively. Using multinomial logistic regression models to account for the substantial differences in socioeconomic status between foreign-born and US-born children, we found that low-income US-born children were just as likely as foreign-born children to have public health insurance coverage (odds ratio [OR] = 1.16; 95% confidence interval [CI] = 0.89, 1.52) and that, after 2000, foreign-born children were 1.59 times (95% CI = 1.24, 2.05) more likely than were US-born children to be uninsured (vs publicly insured).Conclusions. In the wake of the reversal of the public charge rule, immigrant children are increasingly likely to be uninsured as opposed to relying on public health insurance.Recent attention has focused on immigrants’ use of public programs, especially health insurance programs, in the United States.^1–6 According to the 2000 census, 1 of every 5 children is a member of an immigrant family, and immigrants are increasingly dispersed across the country.⁷ Immigrant families are also complex in that parents and children may differ with respect to their immigration status. In 1998, 10% of children in the United States lived in “mixed-status” families composed of at least 1 noncitizen parent and at least 1 citizen child.⁸Because most children depend on their parents to obtain necessary benefits, including health insurance coverage, parental immigrant status may influence a child''s health insurance status and, ultimately, his or her health outcomes.⁹ As immigration rates continue to increase, these demographic shifts mean that the health of immigrant children will have a significant impact on the socioeconomic future of all Americans.Federal, state, and local policies can promote or hinder health insurance coverage for immigrants. The past 12 years have seen a pair of major policy changes designed to reduce immigrant enrollment in publicly funded health insurance programs. First, the Personal Responsibility Work Opportunity and Reconciliation Act of 1996 (commonly known as welfare reform) ruled that immigrants residing in the United States for less than 5 years were no longer eligible for any federally funded public benefits, including health insurance.¹⁰ In response, some states created public health insurance programs to cover immigrants with state funds.¹¹ Federal legislation to extend coverage to lawfully residing immigrant children continues to be debated.¹²Second, the “public charge” rule of the Illegal Immigration Reform and Immigrant Responsibility Act of 1996 was initially interpreted as requiring families to repay the US government for public benefits, including Medicaid, previously received at no cost.¹³ In response to collective advocacy efforts by health care providers and community-based organizations, the government specified in May 1999 that Medicaid benefits would be exempted from the public charge rule.¹⁴ In the wake of these rapid changes, there have been concerns about health care access for immigrant children, especially given that children require regular health supervision visits and immunizations to promote optimal health and well-being.^2,11,15–17Data from the mid-1990s have been used in most recent studies of health insurance coverage among immigrant children. One study involving data from the 1994 and 1996 versions of the Current Population Survey showed that 44.3% of immigrant children were privately insured, 34.1% were publicly insured, and 27.3% were uninsured.¹⁸ The majority of uninsured children had working parents whose employers failed to provide health insurance coverage or were members of families that did not meet Medicaid eligibility requirements for immigrants.¹⁸ Another study of low-income noncitizen adults and children showed that Medicaid participation rates dropped and that noncoverage rates increased between 1995 and 1998; these changes have been ascribed to confusion about eligibility rules for benefits related to welfare reform.¹⁵The most recent nationally representative analysis of which we are aware (from 1999) confirmed that foreign-born children (approximately 87% of whom were not US citizens⁷) were more likely to be uninsured than to have public health insurance coverage,¹⁹ but the data from that study were collected before the reversal of the public charge rule. In our study, we analyzed data from the 1997 through 2004 versions of the National Health Interview Survey (NHIS) in an effort to determine whether reversal of the public charge rule led to immigrant children becoming increasingly or decreasingly reliant on public health insurance programs.     

Safety-net institutions buffer the impact of Medicaid managed care: a multi-method assessment in a rural state

OBJECTIVES: This project used a long-term, multi-method approach to study the impact of Medicaid managed care. METHODS: Survey techniques measured impacts on individuals, and ethnographic methods assessed effects on safety-net providers in New Mexico. RESULTS: After the first year of Medicaid managed care, uninsured adults reported less access and use (odds ratio [OR] = 0.46; 95% confidence interval [CI] = 0.34, 0.64) and worse barriers to care (OR = 6.60; 95% CI = 3.95, 11.54) than adults in other insurance categories. Medicaid children experienced greater access and use (OR = 2.11; 95% CI = 1.21, 3.72) and greater communication and satisfaction (OR = 3.64; 95% CI = 1.13, 12.54) than children in other insurance categories; uninsured children encountered greater barriers to care (OR = 6.29; 95% CI = 1.58, 42.21). There were no consistent changes in the major outcome variables over the period of transition to Medicaid managed care. Safety-net institutions experienced marked increases in workload and financial stress, especially in rural areas. Availability of mental health services declined sharply. Providers worked to buffer the impact of Medicaid managed care for patients. CONCLUSIONS: In its first year, Medicaid managed care exerted major effects on safety-net providers but relatively few measurable effects on individuals. This reform did not address the problems of the uninsured.     

HCV Infection and Cryptogenic Cirrhosis are Risk Factors for Hepatocellular Carcinoma Among Latinos in New York City

Latinos in the US experience a 60% higher death rate from primary hepatocellular carcinoma (HCC) when compared to Non-Latinos. The goal of this study was to examine risk factors that are associated with ethnic disparities among HCC patients seen at the transplant center of a metropolitan medical center in New York City. We compared HCC risk factors in 140 Non-Latino and 55 Latino patients that presented with HCC from 1995 to 2003. Surnames were used to define Latino and Non-Latino HCC patients in a retrospective analysis. Latino and Non-Latino HCC patients did not vary by gender or age at presentation (mean Latino age 60.8). Latino HCC patients had a higher frequency of presentation with advanced disease, defined as patients with unresectable HCC, than non Latino HCC patients (Latino 52.7%; 95% CI 39.1–66.3 vs. Non-Latino vs. 36.4%; 95% CI 28.3–44.4). Latinos were more likely than Non Latinos to have underlying HCV (34.5 vs. 22.1%, P < .0001; adjusted odds ratio [Siegel, 2008 #564], 3.69; 95% CI, 1.16–11.7) and cryptogenic liver diseases (7.2 vs. 3.5%, P < .0001; OR 8.86; 95% CI, 1.21–65.0) after adjusting for age, gender and alfa-fetoprotein levels. Although more advanced disease may signal delay in access to care or more aggressive disease, HCV infection and cryptogenic cirrhosis at presentation are likely key factors for the greater burden of HCC among Latinos in New York City.     

A community-based collaboration to assess and improve medical insurance status and access to health care of Latino children

OBJECTIVES: Despite eligibility for subsidized insurance, low-income Latino children are at high risk of being medically uninsured. The authors sought to understand and improve access to medical insurance for Latino children living in a California community of predominantly low-income immigrant families. METHODS: During the summer of 1999, trained women from the community conducted interviews in Spanish with 252 randomly selected mothers of 464 children younger than age 19. Mothers provided information about family demographics, children's medical insurance, health care access, and experiences obtaining and maintaining children's insurance. RESULTS: Most children (83.3%) were eligible for subsidized medical insurance (48.4% Medi-Cal eligible; 35.0% Healthy Families eligible). Twenty-eight percent of eligible children were not enrolled. Non-enrolled eligible children were older (median age 7) than enrolled children (median age 4) and more likely to be born outside the U.S. (22.2%) than enrolled children (4.8%). Among children ages 3-18, those not enrolled were less likely to have visited a doctor in the past 12 months (58% compared to 78.7%) and less likely to have a usual source of care (96.3% compared to 99.5%). Mothers of non-enrolled children were more likely than mothers of enrolled children to have less than seven years of education (47.8% compared to 36.4%). Families with non-enrolled children were more likely to report out-of-pocket medical expenses (84.1% compared to 53%). Families with non-enrolled children were more likely to report barriers to the enrollment process, such as problems providing required documents (39.7% compared to 15.1%), problems understanding Spanish forms (19.4% compared to 8.9%), and confusing paperwork (39.7% compared to 24.7%). Most mothers (75.9%) reported that community organizations provided very useful help with children's insurance enrollment. Almost half (48.6%) preferred to receive enrollment assistance from community organizations. Only 43.3% of mothers had heard of the Healthy Families program. CONCLUSIONS: To reach the majority of uninsured Latino children, community-based outreach and insurance application assistance are crucial. Most important, the process of applying for and maintaining coverage in Medi-Cal or Healthy Families must be simplified.