When it comes to kids' access to healthcare in Florida, the state ranks dead last -- after all of the other 49 states and the District of Columbia, according to a recent study.

The report, by the Commonwealth Fund, matches what other studies have shown in the past: Healthcare for children in Florida is dreadful.

The 55-page report found that Florida's care for kids also ranked 37th for quality, 34th for costs, 43rd for equity and 38th for ``potential to lead healthy lives.''

The problem with kids is just part of an overall picture: About 3.8 million Floridians, more than one in every five residents, have no health insurance.

Most of these people don't get regular care, which means they are likely to wait until they get extremely sick and go to an emergency room, where they run up a high bill they can't pay. Hospitals make up for that loss by passing on the costs to those who have insurance, driving up premiums, which causes more people to drop their coverage and accelerate the cycle.

Julieta Romano, a Southwest Dade mother of four, understands the problems well. When she took a second part-time job, her income went $200 a month above the limit for Medicaid, the state-federal program for the poor, and most of her kids were bounced out of the program.

Three of her children could then qualify for Florida Kidcare, a subsidized state-federal program in which parents pay a portion of the costs based on their income level.

`WHOLE NEW PROCESS'

''But it was a whole new process,'' says Romano. 'They couldn't transfer any of my information. Birth certificates. Social Security numbers. Pay stubs. Copies of this and that. I said, `It's in the system already,' but they said it was a different system.''

For almost two months, her children had no coverage. Twice, they got sick and she had to rush them to the emergency room, which resulted in bills of more than $1,000.

Experts say what happened to Romano's children is precisely what's wrong with the system: Too many interruptions in service, which often translates into children having no ''medical home,'' a doctor or clinic where they can get frequent, preventive care -- treatment that often times can avoid much more expensive trips to emergency rooms.

''It is very complex and very difficult to enroll and maintain coverage,'' says Laura Goodhue, executive director of Florida CHAIN, a nonprofit group dedicated to helping people get access to healthcare.

Florida Kidcare, part of the federal-state State Children's Health Insurance Program (SCHIP), has four programs, each with different qualifying requirements. Most parents who sign up for the program have jobs. As their income levels change, or as their children grow older, they must shift from one program to another, re-applying each time and providing stacks of documents.

Because of complexities like that, Goodhue says, 500,000 children in the state who are eligible for Kidcare are not enrolled.

Goodhue said this year's legislative session took some positive steps to help children, including requiring insurance companies to cover some treatments for autistic children and expanding Kidcare to include more families. But moves to simplify enrollment and renewal for Kidcare went nowhere as did attempts to get more dollars to inform those eligible how to sign up for the programs.

The Commonwealth study, released last month, showed that states in the Northeast and Midwest generally ranked far above states in the Southeast. Iowa ranked No. 1 overall. Joining Florida at the bottom were Oklahoma, Mississippi, Louisiana, Arizona and Texas.

Commonwealth's data confirms other studies. Last year, the Miami-Dade County Community Health Report Card, prepared by the Health Council of South Florida, graded children's and mothers' care as a D-plus.

A key indicator in Miami-Dade was the rate of children admitted to the hospital for asthma problems. ''This is a highly treatable condition,'' says Julie Zaharatos of the health council.

If an asthmatic child regularly sees a doctor, there's virtually no reason why the condition should lead to a hospitalization.

Yet in Miami-Dade, where many children are uninsured and do not get regular healthcare, hospitalizations for children with asthma programs were 339.4 per 100,000 in 2004, 46 percent more than the rate in Massachusetts. ''These are all coded and reported as preventable hospitalizations,'' says Zaharatos.

PROBLEMS IN BROWARD

Comparable figures are not available for Broward, but research from the Broward Regional Health Planning Council indicates other problems: healthy-start screening rates for early detection of health problems for prenatals and infants are at least 10 percent below the state average. However, 89.2 percent of Broward 2-year-olds have received immunizations, compared to 85.3 percent of children in the state.

Many groups are working to improve child healthcare locally.

The Children's Trust in Miami-Dade is working to use healthcare professionals in schools to improve treatment for students.

The Health Foundation of South Florida has an initiative to improve dental care for children. ''We have real issues here trying to provide oral health for children,'' says Steven Marcus of the foundation. ``If you don't have good oral health, that leads to problems down the road.''

But in many measures, Florida is so far behind that some have just about given up hope.

Juan Carlos Guardiola, a self-employed Miami-Dade singer who can't afford insurance, has a daughter, Swan Moon, who has just turned 4 and has Down's syndrome. She's just getting to the age where she could benefit from enrolling in a school for kids like herself, but Guardiola says he and his wife can't afford it.

''Thank God I have a wife who is bright and determined,'' says Guardiola, who performs under the name Johnny Dread. ``Every time we apply for something, there are all kinds of red tape. My wife's been doing that, but the situation is terrible. . . . We're just so close to moving to Spain or France or somewhere else, where everybody has a right to healthcare.''

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