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As the nation continues to struggle with a growing number of uninsured people, the only bright spot is children. The State Children's Health Insurance Program (SCHIP), enacted in 1997, along with expansions of Medicaid in the l980s and 1990s, led to fewer uninsured children at the same time that the number of uninsured adults rose (Bhandari and Gifford 2003; Hoffman, Carbaugh, and Cook 2004; Kenney, Haley, and Tebay 2003; Rhoades and Cohen 2003; Strunk and Reschovsky 2004).

Studies also show pronounced differences in access and use between children with and without health insurance (Holl et al. 1995; Stoddard, St. Peter, and Newacheck 1994), but SCHIP and the expansions of Medicaid have improved access to care and service use for newly insured children (Dick et al. 2004; Lave et al. 1998; Van Landeghem and Brach 2004). While the assumed relationship between increased availability of insurance coverage and the improved health status of children has not been demonstrated definitively, studies have shown a relationship for some populations (for reviews of this literature, see Hadley 2003; Starfield and Shi 2004).

Despite this progress, many children in the United States are still not insured. Since 1998 the greater number of immigrants into the United States has accounted for much of the growth of the uninsured (Fronstin 2005). In particular, immigrant children, especially Hispanic immigrant children, are far more likely to be uninsured than other children are. The greatest problem is that many such children are undocumented and therefore do not qualify for Medicaid or SCHIP (Capps et al. 2004). "Undocumented" children are those who are not residing in the United States legally, although children born in this country may be documented when their parents are not.

Even when children are eligible for public programs, immigrant parents face numerous barriers to enrolling them, such as lack of familiarity with insurance and limited proficiency in English (Alker and Urrutia 2004; Doty 2003; Fix and Capps 2002; Hughes et al. 2000; Reardon-Anderson, Capps, and Fix 2002;Weathers et al. 2004). In addition, many immigrant parents worry that enrolling their children might constitute a "public charge," thereby inhibiting their ability to obtain permanent residency (Perry, Stark, and Valdez 1998).

California's children face many of the same barriers to obtaining health insurance and adequate health care as do children across the nation (Grossman-Swenson and Dominguez-Arms 2004; Manos et al. 2001; Tomas Rivera Policy Institute 2002). Among California's uninsured children, 60.8 percent are documented and thus eligible for either Medi-Cal (Medicaid) or Healthy Families (SCHIP). The remainder are ineligible because of their documentation status or because their household incomes are too high (Brown and Lavarreda 2005). Although the state does not offer full public coverage to undocumented children, they are entitled to Emergency Medi-Cal for two months for medical emergencies and to preventive care through the Child Health and Disability Prevention Program.

This is an electronic version of an article published in The Milbank Quarterly: complete citation information for the final version of the paper, as published in the print edition of The Milbank Quarterly, is available on the Blackwell Synergy online delivery service, accessible via the journal's website at www.blackwellpublishing.com/milq or www.blackwell-synergy.com.

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