The United States is the only wealthy post-industrial nation that does not provide universal health insurance to its population. Instead, over time, a patchwork of programs for specific populations has been legislatively enacted. The incremental politics of coverage expansions at the federal level has always involved the framing of the new populations as ‘deserving’: first veterans, the elderly and then children. The State Children's Health Insurance Program (SCHIP) created in 1997 and renamed the Children's Health Insurance Program (CHIP) when it was reauthorized in 2009, along with expansions in the Medicaid program, is responsible for a large decrease in the number of uninsured children up until 2018. Even after the implementation of the Patient Protection and Affordable Care Act of 2010 (ACA), US children were and still are far more likely to have health insurance coverage than are adults under the age of 65.

The expansion of health insurance coverage for US children during the last three decades was not achieved easily or without conflict. It was made possible by the development of a child health advocacy community both inside and outside of government, beginning in the 1980s. While a bipartisan congressional consensus was achieved during SCHIP's creation, its subsequent reauthorizations were marked by ideological and partisan conflict, a product of which political party controlled the legislative and executive branches of the federal government. The policy history of children's health insurance has also been intertwined with efforts to enact universal health coverage, and once that was nearly achieved, to determine whether a separate children's health insurance program was still needed.

This chapter analyses the policy processes related to federal funding of US children's health insurance from the mid-1980s through its latest legislative extension in 2018. I discuss the roles of child health advocates, the ‘framing’ of the program, how policy issues and events connected to universal coverage interfaced with children's coverage, and, finally, how central issues in the policy debates over children's health insurance are reflections of the deep fissures in US politics about the role of government in social welfare policy. I end with a brief description of the situation in 2021 at the time of writing, as the number of uninsured children in the United States has begun to increase as a result of both Trump administration policies and the effect of the Covid-19 pandemic.