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Public dental insurance programs for children aim to provide access to care, but barriers remain that preclude care delivery. Understanding these barriers is an important health policy concern. A telephone audit sought to ascertain availability of oral health care for children in dental offices eligible to bill Medicaid. Female callers posing as mothers called eligible offices requesting appointments. In this cross-over design, offices were randomized to public or private insurance for initial calls and then to the other condition after a washout period. Using mixed models, privately insured patients had 5.9 times (95% CI, 4.55 to 7.69) greater odds of obtaining an appointment than Medicaid patients. Compared with patients in Cook County, suburban patients had slightly better odds, whereas nonurban patients in larger and smaller rural counties had lower odds of success. Medicaid compares poorly with private insurance for providing access to pediatric oral health care. Regardless of insurance conditions, access is poor in less urban environments compared with metropolitan communities. Even Medicaid-enrolled dental practices limit the care they extend to insured children. Providing Medicaid by itself cannot overcome large oral health care access disparities, which are greatest in rural communities. [ABSTRACT FROM AUTHOR]