OBJECTIVES: To determine the difference between children with private and public insurance at the time of referral to a pediatric otolaryngologist. STUDY DESIGN: Prospective study. SETTING: Tertiary care hospital. SUBJECTS AND METHODS: Data relating to the severity of a patient's otitis media (number of infections, doctor visits, antibiotic courses) were collected by phone interview. All patients referred to a pediatric otolaryngologist at an urban tertiary care hospital over a 5-month period were included. RESULTS: One hundred eighty-three children were studied: 87 consecutive patients in the private third-party insurance group (PIN) and 96 patients in the state-based Medicaid insurance group (PA). During the 6 months prior to referral, children in the PIN group had a median 4 acute otitis media infections with 5 courses of oral antibiotics and 6 primary care visits compared to 3 infections with 3 courses of antibiotics and 4 primary care visits for the PA group (P = .0009, P = .0001, P = .0003, respectively). For recurrent acute otitis media, the PA group had a significantly longer time with disease prior to referral than the PIN group (P = .0478). CONCLUSION: Children in this metropolitan area referred for tympanostomy tube placement with PIN are younger, have more episodes of acute otitis media, receive more antibiotic courses, and have more primary care visits in the 6 months prior to referral than their PA counterparts. Additional research is required to determine why these differences exist, especially in light of ongoing changes to the health care system.