CHAPTER 4
Public Policies

This chapter summarizes the current policy status of children in immigrant families and places this contemporary portrait in the context of previous immigration and social welfare policies that have determined their access to health and social services over time. It analyzes new data, collected for the committee, on the use of benefits by immigrant families prior to welfare reform. The chapter then provides information about health care for children in immigrant families. It examines patterns of health insurance coverage, access to and use of health services, and barriers to access.

It is beyond the scope of this report to do more than touch on the highlights of U.S. immigration history (see also Barkan, 1996; Bodnar, 1985; Daniels, 1990; Hing, 1993; Kraut, 1982; National Research Council, 1997), let alone social welfare history. Nevertheless, it is important to have some understanding of earlier practices and policies that have, by design, brought foreign-born children to the United States and provided for them once they arrived.



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From Generation to Generation: The Health and Well-Being of Children in Immigrant Families CHAPTER 4 Public Policies This chapter summarizes the current policy status of children in immigrant families and places this contemporary portrait in the context of previous immigration and social welfare policies that have determined their access to health and social services over time. It analyzes new data, collected for the committee, on the use of benefits by immigrant families prior to welfare reform. The chapter then provides information about health care for children in immigrant families. It examines patterns of health insurance coverage, access to and use of health services, and barriers to access. It is beyond the scope of this report to do more than touch on the highlights of U.S. immigration history (see also Barkan, 1996; Bodnar, 1985; Daniels, 1990; Hing, 1993; Kraut, 1982; National Research Council, 1997), let alone social welfare history. Nevertheless, it is important to have some understanding of earlier practices and policies that have, by design, brought foreign-born children to the United States and provided for them once they arrived.

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From Generation to Generation: The Health and Well-Being of Children in Immigrant Families PROVISION OF PUBLIC BENEFITS Current Eligibility The most important policies affecting immigrants after arrival in the United States have been the fairly generous rules that have governed access by legal immigrants to mainstream public benefit programs, such as income support (formerly Aid to Families with Dependent Children, AFDC), health and nutrition benefits, social services, and public education. Following several years of intense national debate over the costs of immigration, particularly over the use of public benefits by immigrants, the 104th Congress enacted the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (hereafter referred to as welfare reform). This law, among other changes, fundamentally altered the legal structure for providing these public benefits to immigrants, adults and children alike.1 The Balanced Budget Act of 1997 substantially reversed several major provisions of welfare reform, restoring roughly half of the $23 billion ($11.4 billion) in federal savings that were expected to result from the provisions targeted to immigrants (Congressional Budget Office, 1997). And, as of this writing, efforts to restore benefits to immigrants are ongoing at the federal level. The law's impact on immigrant children derives in large part from the programmatic reach of new restrictions on immigrants' eligibility for public benefits, which encompass the benefit programs of Medicaid, Supplemental Security Income (SSI), the Food Stamp Program,2 and noncash services (such as child care) delivered under Temporary Assistance to Needy Families (TANF, for- 1   The Illegal Immigration Reform and Immigrant Responsibility Act of 1996 affected similar aspects of immigration law, but these changes were reconciled to the provisions of the welfare reform law and thus are not discussed here. 2   On June 23, 1998, as this report was being prepared for publication, President Clinton signed the Agriculture Research, Extension, and Education Reform Act (S. 1150) which restored food stamps to 250,000 legal immigrants, including 75,000 children who lost benefits under the welfare reform bill. This figure represents about one-quarter of the approximately 935,000 legal immigrants who lost their food stamp eligibility under the welfare law.

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From Generation to Generation: The Health and Well-Being of Children in Immigrant Families merly Aid to Families with Dependent Children). Not only have immigrant children been direct beneficiaries of many of these programs, but also many of those who did not receive benefits themselves live in families in which a family member was eligible for and received benefits. For example, children constituted an estimated 17 percent of noncitizens losing food stamps, but almost two-thirds (64 percent) of households headed by a noncitizen that received food stamps also included children (Smolkin et al., 1996). To the extent that overall family resources for meeting basic needs are reduced, children in immigrant families will be likely to feel the impacts. These concerns about the possible negative effects of the policy changes on children in immigrant families have been met by alternative views that emphasize possible deterrent effects of the changes on future immigration and on immigrants' interest in and ability to remain in the United States. Five shifts in public policy introduced by welfare reform are particularly significant for immigrant children. (Tables 4-1 and 4-2 summarize the major changes in eligibility for benefits that have arisen from this recent legislation.) First, the law draws a new line between legal immigrants and citizens in determining eligibility for public benefits; such a line was formerly drawn between illegal and legal immigrants. Prior to welfare reform, legal immigrants were eligible for public benefits on essentially the same terms as U.S.-born citizens (Fix and Zimmerman, 1995).3 Currently, most immigrants (except for refugees) who are in the United States legally are barred from eligibility for food stamps, 3   Naturalized citizens enjoyed the same entitlements as other citizens. Refugees, whose flight from persecution in their homeland is considered unplanned migration, were also entitled to receive full public benefits from the time of their arrival. Access of legal permanent residents to SSI, food stamps, and AFDC benefits was conditioned by "deeming," that is, ascribing the incomes of their sponsors to the immigrants for three to five years following entry. Undocumented immigrants were eligible for very few public benefits, most notably emergency medical assistance under Medicaid and the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). The Supreme Court ruled in 1982 that undocumented alien children could not be denied access to public elementary and secondary education (Plyler v. Doe, 457 U.S. 202(1982)). U.S.-born children of undocumented aliens are citizens of the United States and are eligible for public benefits on the same terms as other citizens.

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From Generation to Generation: The Health and Well-Being of Children in Immigrant Families TABLE 4-1 Program Eligibility Prior to Welfare Reform   Legal Immigrants (Permanent Residents) Refugees / Asylees Undocumented Immigrants (Illegal Immigrants) Food Stamps Income of sponsor deemed for 3-5 years after entry Same eligibility rules as citizens. Ineligible. WIC Same eligibility rules as citizens. Same eligibility rules as citizens. No bars to eligibility. School Lunch Same eligibility rules as citizens. Same eligibility rules as citizens. Eligible. SSI Income of sponsor deemed for 3-5 years after entry Same eligibility rules as citizens. Ineligible. MEDICAID Same eligibility rules as citizens. Same eligibility rules as citizens. Eligible for emergency services only. Title XX Social Services Same eligibility rules as citizens. Same eligibility rules as citizens. Eligible. AFDC Income of sponsor deemed for 3-5 years after entry Same eligibility rules as citizens. Ineligible. State and Local Benefits Same eligibility rules as citizens. Same eligibility rules as citizens. Eligibility requirements varied by state. Head Start Same eligibility rules as citizens. Same eligibility rules as citizens. No bars to eligibility. Maternal and Child Health Same eligibility rules as citizens. Same eligibility rules as citizens. No bars to eligibility. Child Care Block Grant Same eligibility rules as citizens. Same eligibility rules as citizens. No bars to eligibility.

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From Generation to Generation: The Health and Well-Being of Children in Immigrant Families and immigrants who arrived after August 22, 1996, are barred from a range of other federal means-tested benefits, including income assistance (TANF) and Medicaid for their first five years in the country. Noncitizens' eligibility for SSI, which was restricted under welfare reform, was restored in the Balanced Budget Agreement of 1997. The restoration was limited, however, to elderly and disabled immigrants who were receiving SSI benefits at the time welfare reform was enacted or who were in the United States on August 22, 1996, and who later become disabled. Future immigrants will be barred—a change that will affect immigrant children largely indirectly, through a loss of benefits to adult family members who constitute the major share of immigrants receiving SSI. In addition, many of the benefits for which undocumented children were previously eligible are likely to be withdrawn. This includes the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), most services provided under the Title XX Social Services Block Grant, and Head Start. Undocumented children retain their eligibility for emergency Medicaid, public immunization programs, and the school lunch program. The place of the recently enacted State Children's Health Insurance Program (SCHIP) in this reformulation of eligibility remains unclear, although it appears that it will be considered a federal means-tested program and so will follow the rules that apply to Medicaid. This program, enacted as part of the Balanced Budget Act of 1997, provides funds to states to enable them to initiate and expand the provision of child health insurance to uninsured, low-income children under age 19. States may spend the new funds in one of three major ways: to extend Medicaid coverage to additional children, to support a separate state child health insurance program, or to do a combination of the two. States may also spend 10 percent of the funds for outreach activities, administrative costs, or direct purchase or provision of health services to children. Within this overall structure, states have broad discretion in fashioning their programs with respect to specific issues such as eligibility, benefits, and cost sharing (see English, 1998; Institute of Medicine, 1998). States are still required, however, to provide

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From Generation to Generation: The Health and Well-Being of Children in Immigrant Families TABLE 4-2 Post-Welfare Reform Program Eligibility   Legal Immigrants (Permanent Residents) Arriving before August 23, 1996 Legal Immigrants (Permanent Residents) Arriving after August 23, 1996 Refugees / Asylees Undocumented Immigrants (Illegal Immigrants) Food Stamps (Federal) Ineligible.a Ineligible. Eligible, time limit is 5 years after admission Ineligible. Food Stamps (State) Eligibility varies by state. Eligibility varies by state. State option to provide benefits after refugees have been in the U.S. more than 5 years Ineligible. WIC Eligible. Eligible. Eligible. Eligibility varies by state. School Lunch Eligible. Eligible. Eligible. Eligible. SSI Legal aliens who were receiving SSI benefits and legal aliens in the country before August 22, 1996 who will become disable will continue to be eligible Ineligible with certain exceptions Eligible for 7 years after entry Ineligible. Medicaid State option. Barred for first 5 years; state option afterwards Eligible for 7 years after entry Ineligible.

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From Generation to Generation: The Health and Well-Being of Children in Immigrant Families Emergency Medicaid Eligible. Eligible. Eligible. Eligible. Title XX Social Services Eligible. Eligible. Eligible. Ineligible. TANF State option. Barred for first 5 years; state option afterward Eligible for 5 years after entry Ineligible. State and Local Benefits State option. State option. Eligible for 5 years after entry Ineligible, unless state passes law explicitly authorizing. Head Start Same eligibility as citizens. Same eligibility as citizens. Same eligibility as citizens. Not yet determined. Maternal and Child Health Same eligibility as citizens. Same eligibility as citizens. Same eligibility as citizens. Not yet determined. Child Care Block Grant Same eligibility as citizens. Same eligibility as citizens. Same eligibility as citizens. Not yet determined. a Except lawful permanent residents who have worked 40 qualifying quarters who did not receive any means-tested federal benefits during that period, and aliens who have served in the U.S. military, who are eligible.

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From Generation to Generation: The Health and Well-Being of Children in Immigrant Families legal immigrants with some health and social service programs, such as those delivered under the Community Health Services Program, the Migrant Health Program, services delivered under the Public Health Services Act, and the Maternal and Child Health Block Grant, many of which are extremely important to immigrant families. Furthermore, the 10 percent funds for outreach and direct provision of health services included as part of SCHIP may presumably be used for services, such as migrant health centers, that immigrant families have traditionally used. Second, refugees arriving after August 22, 1996, will be eligible for SSI and Medicaid for seven years and for TANF and food stamp benefits for five years following their arrival. This change represents a significant departure in refugee resettlement policy by imposing time limits on benefits, which were previously unrestricted. In addition, refugees who were here prior to welfare reform are also subject to the five-year limitation on food stamp benefits. About 10 percent of immigrants in any given year are refugees (Fix and Passel, 1994), but they comprise a substantial proportion of some immigrant groups, such as Cubans, Eastern Europeans, and Southeast Asians. Third, the locus of many decisions affecting immigrant children's eligibility for benefits has shifted from the federal government to the states. States will be faced with an intricate array of eligibility requirements and sponsorship rules. For example, states are in the process of determining current immigrants' eligibility for such major benefits as income assistance and health insurance (the new federal restrictions apply largely to future immigrants). To date, none of the major immigrant-receiving states (California, Florida, Illinois, New York, and Texas) has limited current legal immigrants' access to TANF, Medicaid, or Title XX block grant programs. States are, however, showing wide variation in their decisions about whether to replace lost federal funds with state-funded programs for immigrants arriving after the enactment of welfare reform. This devolution of responsibility for immigrant policy is likely to result in substantial state and even within-state variation in the benefits that both legal and undocumented immigrant children receive. For example, although California has decided to eliminate undocumented children from WIC, other states such as New

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From Generation to Generation: The Health and Well-Being of Children in Immigrant Families York have not. Furthermore, some states such as Maryland and New York have decided to use state funds to provide food assistance to immigrant children, but not to adults. In New York, these funds are provided as part of a cooperative state-county program. As a result, noncitizen children, youth, elderly, and disabled food stamp recipients in New York City have retained benefits, but their counterparts in other New York counties (e.g., Erie County) have not. Fourth, new mandatory federal reporting requirements compel state agencies that administer federal housing, SSI, and TANF programs to furnish the U.S. Immigration and Naturalization Service (INS) four times each year with names, addresses, and other qualifying information on any immigrants known to be unlawfully in the United States. Some are concerned that enactment of this new responsibility by agencies that serve immigrant children will act as a disincentive for undocumented parents of citizen and legal, noncitizen children to seek aid for which these children are eligible and from which they could benefit. However, this remains an open question. Fifth, the requirement for verification of immigration status has been expanded to apply to all ''federal public benefits," the definition of which remains to be determined but could be quite broad. Likely to be included, for example, is Head Start, maternal and child health programs, the Child Care and Development Block Grant, and other programs that have benefited immigrant children. Children who apply to enroll in these programs will now be required to verify their immigration status, which could create a disincentive to enrollment, particularly for children whose parents are undocumented. In addition, the INS has recently promulgated long and complex new regulations that set out the new verification requirements for federal programs (Federal Register, November 17, 1997:61345-61416) and will be providing requirements for verification in state and local benefit programs. Complexity could give rise to confusion among implementers and, accordingly, inconsistent service delivery. In sum, children in immigrant families, including those who have entered and are residing in the United States legally, now face major new restrictions and constraints on eligibility for benefits ranging from income supports to nutrition and health cover-

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From Generation to Generation: The Health and Well-Being of Children in Immigrant Families age. Their access to these benefits will now be conditioned by their date of arrival in the United States, entry status, state of residency, and progress through the naturalization process. This represents a marked shift in the nation's policies for immigrant children. Access Prior to Welfare Reform Throughout America's history, immigrants have had a profound effect on the composition of the country's population and have presented daunting social and economic challenges to successive American generations. During the last century, federal immigration or admissions policies have played a deliberate role in shaping the number and characteristics of foreign-born people admitted to the United States. These policies have been inclusionary by both historical and international standards (Melville, 1995), as well as comprehensive and explicit in their intent and rationale (for more information on the history of U.S. immigration, see National Research Council, 1997). More recently, they have been accompanied by policies that focus on the control of illegal immigration, including intensive border enforcement, employer sanctions, and verification and reporting requirements in the workplace and in social service agencies. Characteristics of the current wave of immigrants have been shaped to a large extent by: (1) the 1965 amendments to the Immigration and Nationality Act, which established family reunification as a central basis for immigration4 and removed the numerical cap on the immigration of immediate relatives of U.S. citizens (a priority that was reasserted by the 1990 Immigration Act); (2) growth in humanitarian admissions fostered by the Refugee Act of 1980, which also established a program for settling and 4   It is important to note that, although public debate sharply distinguishes between family-based and employment-based admissions, this distinction is blurred in practice. Nearly half of employment-preference immigrants are the spouses and minor children of the principal beneficiary. The great majority of doctors and engineers admitted to the United States in fiscal 1995, for example, entered under family unification and other nonlabor criteria (U.S. Immigration and Naturalization Service, 1995).

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From Generation to Generation: The Health and Well-Being of Children in Immigrant Families assisting refugees; (3) the Immigration Reform and Control Act (IRCA) of 1986, which established inclusionary strategies, such as the legalization of 2.7 million formerly illegal immigrants, as well as exclusionary strategies to control illegal immigration; (4) the Immigration Act of 1990, with provisions for doubling the visas available for highly skilled immigrants and their families from 58,000 to 140,000 per year, authorizing the creation of a new category of "diversity immigrants" who would be admitted from countries that had sent comparatively few immigrants to the United States historically, and opening a significant new door to safe refuge in the United States by creating a temporary protected status; and (5) the Illegal Immigrant Reform and Immigrant Responsibility Act of 1996, which requires that sponsors of legal immigrants have incomes that exceed 125 percent of the poverty line, after taking into account the sponsor, his or her family, and the arriving immigrant and family members accompanying the arriving immigrant. The overall impact of these policies has been, thus far, to increase the number and share of immigrants from developing countries, notably Mexico, Southeast Asia, and Central America, many of whom have low labor market skills relative to the U.S.-born population (National Research Council, 1997). In contrast to these relatively unrestricted, comprehensive, and explicit immigration policies, the United States has had no explicit immigrant policy guiding the settlement and orientation of immigrants, or determining the nature and amount of public benefits available to immigrants after arrival (Fix and Passel, 1994; Simon, 1989); the exception is resettlement policies focused on refugees. Instead, immigrants have experienced varied eligibility criteria in the context of specific legislation regarding public benefits. Different immigrant groups have had very different access to resources depending on the array of private, philanthropic, and government programs and benefits available to them at their time and place of arrival. The degree to which private agencies and federal, state, and local governments have shouldered or shared primary responsibility for providing resources needed by children in immigrant families to ensure their healthy development has also changed over time.

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From Generation to Generation: The Health and Well-Being of Children in Immigrant Families aid coverage (64 percent) rather than employment-based health insurance (24 percent). This holds as well for second-generation children in families from these sending countries, despite their parents' relatively low educational levels, high poverty rates, and low participation in the labor force. These children and families from Southeast Asia have been granted refugee status since 1975, which opens the door to relatively generous Medicaid eligibility provisions. USE OF HEALTH CARE Given that health insurance facilitates the access of children to care, differences in coverage should be reflected in differential patterns of access to and use of health care. But access to health care services depends on more than health insurance coverage; it also requires that families develop a connection to the health care system for their children—a regular practitioner or place that can provide continuity of care over time and even across family members and serve as a guide to appropriate preventive care and needed specialized services. Having a regular source of care has been found consistently to increase the use of health care services and to enhance referrals to complex care when needed (Andersen and Davidson, 1996; Berk et al., 1995; Newacheck et al., 1996). Children who are publicly or privately insured are more likely to be connected to the health care system through a doctor (Holl et al., 1995; Kogan et al., 1995; Lieu et al., 1993; Newacheck et al., 1996). There is virtually no research on the access of immigrant children and adolescents to health care, nor on the factors that affect access for this population. The analyses conducted for the committee (Brown et al., 1998) used the number of physician visits "during the past 12 months" as the best available measure of access. This measure combines visits for illness care together with those for preventive care. It is reasonable to assume that children who do not receive at least the minimum number of visits annually that are recommended by the American Academy of Pediatrics (AAP) will not be receiving adequate preventive care. Of course, even if they receive the minimum number of visits, the content of the care may not meet AAP recommendations.

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From Generation to Generation: The Health and Well-Being of Children in Immigrant Families These analyses revealed that first-generation children are less likely than either second- or third- and later-generation children to have had at least one doctor's visit during the previous 12 months (Table 4-6). One-third (32 percent) of first-generation children had not visited a doctor, compared with 18 percent of second- and third- and later-generation children. These differences were found between first-generation and U.S.-born (second- and third-generation) Hispanic, Asian, and white, but not black, children. For all ethnic groups, first-generation children were also found to be more likely (28 percent) than second-generation children (8 percent) and third- and later-generation children (5 percent) to lack a usual provider or source of health care (Figure 4-2). However, Hispanic children in immigrant families were less likely to have a usual provider or source of care than are non-Hispanic children in immigrant families. The vast majority of second- and third- and later-generation children of all ethnicities, including Hispanics, are connected to a usual source of care. The patterns for first- and second-generation children hold regardless of their health insurance status—whether they are uninsured, have Medicaid coverage, or have private or other coverage. However, as has been demonstrated repeatedly for children in general, without health care insurance, children in immigrant families are less likely to have a connection to the health care system (51 percent lack a usual source of care) than those having coverage. Other evidence indicates that the expansions in Medicaid eligibility that characterized the mid-1980s to early 1990s led to comparable and substantial decreases in the share of children who went without any doctor's visits in a 12-month period (Currie, 1997). This was the case for children in immigrant families (with at least one immigrant parent) and U.S.-born children in U.S.-born families, despite lower enrollment on the part of immigrant children relative to their eligibility rates (approximately 50 percent of the eligible children in immigrant families were covered, compared with 66 percent of the eligible children of the other group). For U.S.-born children with U.S.-born parents—but not for children in immigrant families—becoming eligible for Medicaid was also associated with increases in hospitalization rates. Both health insurance coverage and having a usual source of

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From Generation to Generation: The Health and Well-Being of Children in Immigrant Families TABLE 4-6 Children Who Did Not See a Doctor in the Past Year (Percentage), 1994   All ages (0-17) Ages 0 to 2 years Ages 3 to 5 years Ages 6 to 17 years All Children         Immigrant Child 32 8 16 35   (28,36) (0,19) (7,24) (31,40) Child U.S.-Born, Immigrant Parents 18 6 10 26   (16,19) (4,8) (8,13) (23,28) Child and Parents U.S.-Born 18 5 10 23   (17,19) (4,6) (9,12) (23,24) Hispanic         Immigrant Child 39 * 19 42   (33,45)   (4,34) (35,49) Child U.S.-Born, Immigrant Parents 20 7 11 30   (17,23) (4,11) (6,15) (26,34) Child and Parents U.S.-Born 17 3 9 25   (15,20) (1,6) (5,13) (22,29) Asian         Immigrant Child 34 * 8 39   (26,43)   (0,43) (30,48) Child U.S.-Born, Immigrant Parents 20 5 13 28   (16,24) (0,11) (6,21) (22,34) Child and Parents U.S.-Born 17 * * 25   (8,26)   (12,38)   Black         Immigrant Child 19 * * 21   (8,30)     (9,33) Child U.S.-Born, Immigrant Parents 14 9 10 18   (8,19) (0,18) (0,20) (10,27) Child and Parents U.S.-Born 23 8 12 29   (21,24) (5,11) (9,15) (27,32) White         Immigrant Child 27 7 19 29   (21,33) (0,25) (4,34) (22,36) Child U.S.-Born, Immigrant Parents 16 4 9 22   (13,18) (1,8) (5,13) (19, 26) Child and Parents U.S.-Born 17 4 10 22   (16,18) (3,5) (9,12) (21,23) Note: Numbers in parentheses are 95% confidence intervals. Source: 1994 National Health Interview Survey. Brown et al. (1998). * Sample size too small to make a reliable estimate.

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From Generation to Generation: The Health and Well-Being of Children in Immigrant Families FIGURE 4-2 Children without a usual person or place for medical care: 1994. Note: Sample size of "Asian Children, U.S.-Born with U.S.-Born Parents" was too small to make a reliable estimate. Source: 1994 National Health Interview Survey. Brown et al. (1998). care independently and strongly affected the probability that a child in an immigrant family made at least one doctor's visit during the year. Children in immigrant families who are uninsured and who have no usual source of care have the lowest probability of having seen a doctor. Those who are uninsured but have a usual source of care, as well as those who have private health insurance or Medicaid coverage but no usual source of care, both have a substantially greater probability of seeing a doctor. Fi-

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From Generation to Generation: The Health and Well-Being of Children in Immigrant Families nally, children who have health care coverage and a usual source of care have the greatest probability of having visited a doctor (Brown et al., 1998). These relationships applied to children regardless of whether they were first, second, or third and later generation. They characterized Hispanic, black, Asian, and white children alike. Analyses that focused on second-generation children and controlled for family income and maternal education, however, found that some ethnic groups fared worse than others when they lacked insurance or a usual source of care. Specifically, Asian children were substantially less likely than other children to have seen a doctor in the past 12 months when they lacked both health insurance and a usual source of care. In sum, children in immigrant families show patterns of primary health care use, as measured by having had a doctor's visit in the past year, that correspond closely to their patterns of insurance coverage and reports of having a usual source of care. These patterns and relationships, in turn, replicate those found in the pediatric health services research literature for children in general. Health care for children in immigrant families, as for all children, benefits from insurance coverage and from families' efforts to establish an ongoing connection with the health care system. BARRIERS TO HEALTH CARE Children do not always get appropriate health care when it is needed. They are dependent on their parents and guardians to seek care and to accept, understand, and implement the advice of health care providers. Having insurance and a regular source of health care facilitates all children's use of health services, but these factors do not guarantee entry into the health care system. Systemic and personal factors can pose barriers that deter children from receiving the care they need (Institute of Medicine, 1994a). With the exception of isolated ethnographic studies (Baer, 1996; Baer and Bustillo, 1993; Gold et al., 1996), there is a dearth of research in this area that is specific to children in immigrant families. It is reasonable to expect, however, that some children in immigrant families may experience the kind of barriers that pri-

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From Generation to Generation: The Health and Well-Being of Children in Immigrant Families marily affect children in low-income families who lack insurance or who receive Medicaid coverage, because they are similarly poor. Children in immigrant families may also experience barriers arising from their parents' lack of knowledge about the health care system in the United States, attitudes about accepting public benefits, or from language and cultural differences between parents and providers. Medicaid and Reduced Access to Care Limited availability of neighborhood-based primary health care facilities is frequently cited as a barrier to appropriate and timely health care by low-income families. Physicians are not required to participate in Medicaid, and 25 percent of U.S. physicians report that they do not include Medicaid patients in their practices. Approximately a third of physicians limit the number of Medicaid patients they treat (Mitchell, 1991) in part because of low fees paid by Medicaid,12 red tape, and potential exposure to greater liability in treating poor, sick patients (Rowland and Salganicoff, 1994). Even Medicaid patients seen by physicians may be referred to public clinics for immunizations (Ruch-Ross and O'Connor, 1994). In view of these problems, it is not surprising that many uninsured and Medicaid-covered children receive care in emergency departments and hospital clinics. Among the Medicaid population, clinics, outpatient departments, and emergency departments account for 37 percent of all visits, compared with 17 percent of visits among the privately insured (Rowland et al., 1992). Both uninsured and lower-income children are less likely to go to a physician's office for their routine care than insured and more advantaged children and youth (Holl et al., 1995; Simpson et al., 1997). Extensive use of emergency departments and clinics undermines continuity of care and leads to lower quality of care (Erzen et al., 1997; Evans et al., 1997; Halfon et al., 1996; Holl et al., 1995; Rodewald et al., 1997), a problem for all children that is exacer- 12   For pediatric and obstetric services, Medicaid reimburses providers at about half the rate of private insurers (Physician Payment Review Commission, 1991).

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From Generation to Generation: The Health and Well-Being of Children in Immigrant Families bated among those with chronic conditions. Moreover, it is not clear how emergency departments and clinics that low-income families rely on and that provide important sources of care for many uninsured children and youth may be affected by the recent wave of hospital closures and mergers, the takeover of not-for-profit hospitals by for-profit companies, and declining government support for public hospitals. The Shift to Managed Care In principle, some features of managed care, such as coordination of care by case managers and assignment of care providers to specific patients on a long-term basis, have the potential to improve access to care in the low-income eligible population. Evidence to date is mixed, however, and there are virtually no data on how immigrant children are faring in managed care settings. A 1995 review of more than 130 studies of Medicaid managed care by the Kaiser Foundation (Rowland et al., 1995) found that managed care reduced use of emergency department and specialist care, but it did not lead to consistent changes in the overall number of doctor's visits. Access to preventive care did not consistently rise or fall, and it remained lower for the Medicaid population than for the nonpoor population. None of the studies in the Kaiser report focused specifically on immigrants. In addition, specialized services such as transportation or language translation, which are needed by many Medicaid beneficiaries and by immigrants as well, may not be offered by conventional managed care plans. Culture and Language For many immigrants arriving in the United States today, access to health care is likely to be complicated by cultural perceptions of health and health care that differ from Western concepts and by communication problems caused by language barriers (de Leon Siantz, in review; Munoz et al., 1986). A rich literature has characterized the ways in which culture shapes perceptions, explanations and experiences of illness, help-seeking patterns, and responses to treatment (Angel and Thoits, 1987; Harwood, 1981;

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From Generation to Generation: The Health and Well-Being of Children in Immigrant Families Kleinman, 1978, 1980). The fears of immigrant parents that health care providers will fail to understand or will even disparage their beliefs about their children's health and health care, whether founded or not, may discourage health care use (Institute of Medicine, 1994b; Keefe et al., 1979), although one study of Vietnamese immigrants found that differing beliefs did not act as a barrier to accessing Western medicine (Jenkins et al., 1996). Furthermore, the dearth of bilingual health care practitioners and multilingual health messages may undermine the ability of immigrant children and their families to receive health information, communicate with health providers, and identify health services in their community (Andersen et al., 1981; Giachello, 1994; Moll et al., 1976; Solis et al., 1990; Wood et al., 1995). There is a strong consensus among health care professionals that the delivery of high-quality health care and mental health services to immigrant children and their families must be done in ways that are culturally competent and culturally sensitive and must take into account language barriers (American Academy of Pediatrics, 1997b). In a study supported by the Health Resources Services Administration, Tirado (1995) defined cultural competence as "a level of knowledge and skills to provide effective clinical care to patients from a particular ethnic or racial group," and cultural sensitivity as "a psychological propensity to adjust one's practice styles to the needs of different ethnic or racial groups." The American Medical Association (1994) defines cultural competence as ''the sensitivity, cultural knowledge, skills, and actions of practitioners that meet the needs of patients from diverse backgrounds." Several guides have been developed to help providers become more culturally competent (see, for example, American Psychiatric Association, 1994; Cross, 1992; Isaacs and Benjamin, 1991; Lynch and Hanson, 1992). They emphasize the importance of valuing cultural diversity, assessing the culture of the health care delivery system and its interface with the cultures represented by the client population, and incorporating knowledge about the culture-based beliefs and practices of the client population into health care delivery. Efforts that involve recognizing social networks and natural helpers have also been discussed in the literature (see Institute of Medicine, 1994b). Yet few applied graduate

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From Generation to Generation: The Health and Well-Being of Children in Immigrant Families medical training programs provide courses that address these issues or offer opportunities to work with diverse populations (Allison et al., 1994). To date, moreover, although there is an extensive literature that argues for the need to deliver culturally competent care, it relies heavily on anecdotal evidence (e.g., case studies, providers' personal experiences) and data from small nonrepresentative samples of patients. Research is clearly needed to develop a body of knowledge about how cultural differences, distinct from differences due to other factors such as social class, function to promote or deter the delivery of appropriate and effective health care to immigrant children. The perspectives of parents and children, as well as of a range of health care professionals, are needed. Important questions concern the effects of culturally competent care or its absence on parents' willingness to seek health care for their children; on the accurate communication of symptoms and diagnoses; and on parents' acceptance, understanding, and appropriate implementation of treatment recommendations. SUMMARY Prior to welfare reform, second-generation children, who account for three-fourths of all children in immigrant families, were nearly identical to third- and later-generation children in their likelihood of living in families receiving public assistance. First-generation children, however, were more likely than second- and third- and later-generation children to live in families with at least one person receiving public benefits. Among Mexican-origin children, who account for about one-third of all children in immigrant families, the first, second, and third and later generations are all more likely than third- and later-generation white children to live in families receiving public benefits. It is disadvantaged socioeconomic and demographic circumstances that account for high levels of public assistance receipt among first-generation children as a whole, and among Mexican-origin children in immigrant families. Indeed, their rates of reliance on public assistance are either similar to or lower than those of third- and later-generation black children, who are also highly disadvantaged. For children with similar socioeconomic and de-

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From Generation to Generation: The Health and Well-Being of Children in Immigrant Families mographic circumstances, both first- and second-generation children, generally, as well as first- and second-generation Mexican-origin children, are less likely than third- and later-generation white children to be living in families receiving welfare from most programs. Beyond generational patterns, it is clear that, with welfare reform, the new restrictions on eligibility for many of the benefits applied to immigrant families are likely to have a disproportionate effect on children whose families are from countries that have either tended to send relatively impoverished people to the United States, such as Mexico, or have been the source of major waves of refugees, such as Southeast Asian nations, Bosnia, and the former Soviet Union. With regard to health care coverage and access, the committee's analyses, which pertain to the situation prior to welfare reform, indicate that substantial disparities in uninsurance rates—not fully explained by family work status or income—characterize children in immigrant families. First-generation children are about three times more likely, and second-generation children are about twice as likely to lack health insurance than are third- and later-generation children. Hispanic children are particularly disadvantaged, showing both high rates of uninsurance and low rates of employer coverage relative to Asian, black, and white children of all generations. In large part due to the automatic eligibility of refugees for Medicaid, Southeast Asian children exhibit very low rates of uninsurance despite their very low socioeconomic status. This, combined with the high rates of employment-based coverage for children from most other Asian sending countries, leaves Asian children in immigrant families overall with rates of insurance coverage that do not differ significantly from those of third- and later-generation white children. It is critical to note that the aggregating by broad ethnic groups, which is required by the small sample sizes of existing surveys, obscures the tremendous variations in patterns of insurance coverage that no doubt characterize children from different counties of origin. When children in immigrant families are insured, they are more likely to have a usual source of care and to have seen a physician. As is true for children in general, both health insurance

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From Generation to Generation: The Health and Well-Being of Children in Immigrant Families coverage and an ongoing connection to the health care system are independently associated with increased reliance on appropriate preventive care. It is their combined effect, however, that most strongly affects children's chances of having seen a physician in the past year. First-generation immigrant children and, to a lesser extent, second-generation children are at higher risk than third- and later-generation children of being uninsured, less likely to have a usual health care provider, and less likely to have seen a doctor in the previous year. The evidence reviewed by the committee consistently indicates that the health behaviors of these children and their parents are not fundamentally different from those of other children and parents. Medicaid coverage, in particular, appears to increase the number of children in immigrant families who make doctor's visits during the year, without simultaneously increasing hospitalization rates or doctor's visits beyond an annual check-up. Recent reductions in health care coverage—affecting potentially 1 in 4 first-generation children if current rates of Medicaid coverage for these children hold—are likely to result in poorer access to health care, fewer usual providers or sources of care, and fewer regular doctor's visits than is already the case for this population of children, who prior to welfare reform were already disproportionately likely to lack insurance and consistent health care.