— The number of American children without health care coverage has been slowly but steadily declining over the past several years even as health care costs continue to rise and fewer employers provide insurance, creating a breach that states have stepped in to fill with new programs and fresh money.

The overall ranks of the uninsured continue to swell, to nearly 46 million Americans at the beginning of this year. But a landmark federal program begun in 1997 to provide health coverage to poor and working-class children and additional measures taken by states across the country have provided health insurance to millions of children who might otherwise go without.

In just the past year, 20 states have taken steps to increase access to health coverage for children and their parents and nine states have reversed actions they took during the 2001-03 economic downturn to limit benefits, according the Kaiser Commission on Medicaid and the Uninsured, part of the Kaiser Family Foundation, which tracks health-care trends. As a result of these and other steps, there are 350,000 fewer uninsured children in the United States than there were in 2000, the foundation reported. Over the same period the overall number of uninsured rose by 6 million.

Ambitious steps like the child health bill just signed in Illinois and the "Dr. Dynasaur" children's health program in Vermont have broadened coverage for children.

While elected officials cannot agree on how to provide or pay for health coverage for uninsured adults, there seems to be a consensus that covering children is medically wise and politically smart.

However, even the situation for children is not uniformly favorable. Eleven states facing political and financial pressure, including Maryland, Pennsylvania and Tennessee, made it more difficult for eligible children to retain coverage.

The movement to expand coverage for children dates to the mid-1990s, after the Clinton administration devised a complex plan to provide all Americans with health-care coverage. That plan failed, and advocates of wider coverage began pursuing more incremental changes at the federal level and lobbying state legislatures to expand coverage.

Alan R. Weil, executive director of the National Academy for State Health Policy, a nonpartisan research group, said that children's health was one area of state spending that had consistently risen, at a time when most other programs — including health care for adults — have suffered cuts. Weil said it was much easier for elected officials to approve spending "for the kids" than to expand welfare programs for adults, even in times of hardship.

"It goes back to the Elizabethan poor laws that drew a conceptual distinction between the deserving and the undeserving poor," he said. "It's very hard to call kids undeserving, even if you don't like the parents' behavior. It's not the kids' fault they are without health care."

As of the beginning of this year, 16 percent of all Americans lacked health insurance, but only 12 percent of children under 18 went uncovered, although that still amounts to 9 million children, according to the Kaiser commission. The gap between the two groups has been widening over the years as fewer and fewer employers offer health care coverage, federal spending on health care fails to keep pace with rising costs, and states are forced to limit eligibility to balance their budgets.

The picture is somewhat brighter for children than for adults in large part because of enactment of the State Children's Health Insurance Program, or SCHIP, in 1997. The program provides federal money for child health care to states, which determine eligibility, income limits and covered benefits within federal guidelines. The number of children covered under the federal-state program grew rapidly at the start, from 897,000 children nationwide in 1998 to 3.95 million in the middle of 2003 before leveling off.

The percentage of uninsured children ranges from less than 5 percent in Vermont to almost 20 percent in Texas. The differences reflect state policies as well as the poverty rate, the number of immigrants, and the percentage of children covered by employers and other programs.

The chief factor determining how many children are covered is the income eligibility level set by the states under SCHIP. The federal government requires coverage for families at or below the federal poverty level, which is now about $20,000 for a family of four. Only a few states set the limit that low. In some states, including Minnesota, Rhode Island and Vermont, families with incomes at 250 percent or even 300 percent of the federal poverty line qualify.

Despite the fading fortunes of the auto industry, 93 percent of Michigan children are covered, several percentage points higher than the national average. But that still leaves 200,000 Michigan youngsters uninsured, and Gov. Jennifer M. Granholm said she considered that a tragedy and a national disgrace.

Even though Granholm intends to ask for significant cuts in some state programs in her budget next month, she said she would propose increasing spending to address the problem of uninsured children.

She said states were cobbling together solutions from shrinking federal budgets and strained state finances to try cover children and their parents while remaining competitive in a global marketplace.

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