Thirty-eight percent of US children depend on publicly financed health insurance, reflecting both its expansion and the steady erosion of employment-based coverage. Continued funding for the Children’s Health Insurance Program (CHIP) is an immediate priority. But broader reforms aimed at improving the quality of coverage for all insured children, with a special emphasis on children living in low-income families, are also essential. This means addressing the “family glitch,” which bars premium subsidies for children whose parents have access to affordable self-only employer-sponsored benefits. It also means addressing the quality of health plans sold in the individual and small-group markets—whether or not purchased through the state and federal exchanges—that are governed by the “essential health benefit” standard of the Affordable Care Act (ACA). In this article we examine trends in coverage and the role of Medicaid and CHIP. We also consider how the ACA has shaped child health financing, and we discuss critical issues in the broader insurance market and the need to ensure plan quality, including the scope of coverage, use of a pediatric medical necessity standard that emphasizes growth and development, the structure of pediatric provider networks, and attention to the quality of pediatric health care.