HONOLULU -- A new nationwide study said thousands of Hawaii children are starting the school year without health insurance.

Most of them could get insurance for free but their parents don't know about the other.

Hawaii used to be one of the best-insured states in the nation, but now, Hawaii is in about the middle among states.

The busy season is under way at Kalihi Palama Health Center, with kids like Paul Dela Cruz needing physicals and shots for school.

Like half the clients at Kalihi Palama, and about 22,000 other children, Paul and Shylee Dela Cruz have no insurance. Their doctor told an aunt helping translate they may have to pay cash.

Many uninsured families don't get medical care they need.

Most likely the Dela Cruz children are eligible for free insurance as low-income legal immigrants.

However, like many other families they didn't know free coverage was available.

"Every time I see a number, even if its one child that's eligible, and they are not insured that's a hardship on the family," said Barbara Luksch of the Primary Care Association.

A new nonprofit survey estimate between 11,000 and about 14,000 Hawaii children are missing out on free insurance. The options are available from the state and federal government. You don't have to be unemployed or on welfare to be covered.

"Many families don't know that they can be working and their children can still get free health insurance. They also don't know that there is no asset test for children, it's only based on income," Luksch said.

Many families are surprised to learn how much they can earn and still be eligible for free coverage for their kids.

In the state of Hawaii, a family of four can earn up to $42,000 a year and still be eligible.