CHAPTER 3
Access to Health Insurance and Health Care for Children in Immigrant Families1

E. Richard Brown, Roberta Wyn, Hongjian Yu, Abel Valenzuela, and Liane Dong

An ongoing concern in immigration research is the extent to which poor access to social and economic opportunities creates structural barriers to immigrants assimilation into the U.S. economy and society (Bean et al., 1994; Lee and Edmonston, 1994). Access to health insurance and health care is an important indicator of socioeconomic opportunity. Access to health care services, particularly for children, is important to ensure that acute and chronic conditions are diagnosed and treated in a timely manner, that health and development are adequately monitored, and that preventive services are provided as recommended (American Academy of Pediatrics, 1995). Without good access to primary medical care, acute conditions, such as middle-ear infections or streptococcus infections, can lead to chronic, often disabling, conditions. Without appropriate medical management, chronic conditions, such as asthma or diabetes, may lead to life-threatening medical emergencies and may impose economic and social burdens on families and society. Without adequate access to preventive care, such as immunizations and well-baby/ child checkups, both chronic and acute conditions are more likely to occur, and developmental problems may go undiagnosed and

1  

 The research on which this paper is based was supported by a grant from the Robert Wood Johnson Foundation.



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Children of Immigrants: Health, Adjustment, and Public Assistance CHAPTER 3 Access to Health Insurance and Health Care for Children in Immigrant Families1 E. Richard Brown, Roberta Wyn, Hongjian Yu, Abel Valenzuela, and Liane Dong An ongoing concern in immigration research is the extent to which poor access to social and economic opportunities creates structural barriers to immigrants assimilation into the U.S. economy and society (Bean et al., 1994; Lee and Edmonston, 1994). Access to health insurance and health care is an important indicator of socioeconomic opportunity. Access to health care services, particularly for children, is important to ensure that acute and chronic conditions are diagnosed and treated in a timely manner, that health and development are adequately monitored, and that preventive services are provided as recommended (American Academy of Pediatrics, 1995). Without good access to primary medical care, acute conditions, such as middle-ear infections or streptococcus infections, can lead to chronic, often disabling, conditions. Without appropriate medical management, chronic conditions, such as asthma or diabetes, may lead to life-threatening medical emergencies and may impose economic and social burdens on families and society. Without adequate access to preventive care, such as immunizations and well-baby/ child checkups, both chronic and acute conditions are more likely to occur, and developmental problems may go undiagnosed and 1    The research on which this paper is based was supported by a grant from the Robert Wood Johnson Foundation.

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Children of Immigrants: Health, Adjustment, and Public Assistance untreated. All of these consequences may create additional barriers to successful adjustment by immigrants to their new society. Health insurance provides an important degree of financial access to health care services. Numerous studies have demonstrated that children who have neither private health insurance or Medicaid or any other public coverage receive fewer physician visits overall, fewer visits for the care of chronic conditions, and fewer preventive health care services compared to insured children (Newacheck et al., 1996; Stoddard et al., 1994; Wood et al., 1990; Brown, 1989). Other factors also influence access. Having a regular provider of care provides a connection to the health care system, facilitating both access to services and continuity of care. Having a regular provider has consistently been found to increase a person's use of health care services (Berk et al., 1995; Andersen and Davidson, 1996). Whether health care services are geographically available to children also has been found to affect their use of ambulatory care services and rates of avoidable hospitalizations (Andersen and Davidson, 1996; Valdez and Dallek, 1991). Cultural factors, including language barriers and customs, affect access for immigrant and other ethnic and racial minority population groups (Aday et al., 1993; Board on Children and Families, 1995). Despite these benefits, the provision of publicly funded health care services to noncitizens in the United States has become a highly charged policy and political issue. The dispute has focused on both legal immigrants' entitlement to federal health and welfare programs and undocumented, or illegal, immigrants' use of government-funded health and educational services (Fix and Passel, 1994; U.S. General Accounting Office, 1995; Clark et al., 1994). Although recent major changes in federal law will affect legal and undocumented immigrants' entitlement to health care services and other programs, few studies have examined immigrants' access to health insurance coverage and health care services (Thamer et al., 1997; Edmonston, 1996). The research and theoretical literature on access to health care has focused considerable attention on disparities by ethnicity and race. Latinos have very high uninsured rates, followed by Asians, African Americans, and non-Latino whites (Mendoza, 1994;

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Children of Immigrants: Health, Adjustment, and Public Assistance Valdez et al., 1993; Wyn et al., 1993). Latinos, African Americans, and Asians also have fewer physician visits than non-Latino whites, for general medical care, acute and chronic conditions, and preventive services (Aday et al., 1993; Wyn et al., 1993; Mendoza, 1994; Lieu et al., 1993; Vega and Amaro, 1994). However, few studies have examined the effects of immigration and citizenship status on health insurance coverage and access to health care, despite its central importance in understanding ethnicity, particularly for Latinos and Asians. FOCUS AND IMPORTANCE OF THIS STUDY This paper examines health insurance coverage and access to health care services among first-generation immigrant children and U.S. citizen or nonimmigrant children in immigrant families, compared to children in nonimmigrant families. The effects of immigration and citizenship status and ethnicity on uninsurance and on access to physician visits are examined. The extent to which immigrant children and U.S. citizen children in immigrant families have higher uninsured rates and/or less access to health care services has important policy and research implications. Recent public policy changes may substantially reduce access for immigrant children and U.S. citizen children with noncitizen parents. In 1996 Congress dramatically reduced the entitlement of noncitizen immigrants to a broad range of federal public assistance programs, including Medicaid. Much of the debate has centered on undocumented and legal immigrant adults, with little attention to the potential impact of sweeping reforms on children—despite the fact that many of the changes taking place disproportionately affect children, particularly immigrant children, and may reduce their access to health care services. These policy changes have increased the importance of understanding factors that affect health insurance coverage and access to health care services among children in immigrant families. METHODS In this study two population-based surveys, the March 1996 Current Population Survey (CPS) and the 1994 National Health

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Children of Immigrants: Health, Adjustment, and Public Assistance Interview Survey (NHIS), were analyzed to assess the effects of immigration and citizenship status, ethnicity, and other factors on health insurance coverage and access to health care services. The CPS is a national, in-person and telephone, cross-sectional survey conducted by the U.S. Bureau of the Census to obtain information on employment, unemployment, and demographic status of the noninstitutionalized U.S. civilian population. The March 1996 CPS contains extensive information on household relationships, sources of income, ethnicity, citizenship, immigration status, nativity, and health insurance coverage of each household member. The CPS includes information on approximately 35,600 children from birth to age 17, usually reported by an adult family member. The NHIS, which is administered by the National Center for Health Statistics, is a national in-person survey of the noninstitutionalized population and includes demographic, health status, and utilization information in the core survey. Special supplements were administered in 1994 to provide additional information on health insurance coverage, reported reasons for lack of coverage, and access to health care services. The 1994 NHIS includes information on approximately 32,000 children from birth to age 17, as reported by an adult family member. The NHIS does not contain information on citizenship status, and it contains only limited information on national origin. Logistic regressions were used to examine the independent effects of immigration status, citizenship, and ethnicity on health insurance coverage and the effects of immigration status, ethnicity, and health insurance coverage on health care access. UNINSURANCE, IMMIGRATION, AND CITIZENSHIP Are children who are noncitizen immigrants at higher risk of being uninsured than citizen children in native-born families? Are U.S. citizen children in immigrant families at higher risk of being uninsured than those whose parents were born in this country? To answer these questions, we compared the health insurance status of children who are immigrant noncitizens, U.S. citizen children in families with one or more immigrant parents, and U.S. citizen children with U.S.-born parents. We used data on children

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Children of Immigrants: Health, Adjustment, and Public Assistance and their families from the March 1996 CPS to examine health insurance coverage. Variables Used in Analysis of Health Insurance Coverage Our analytical approach is based on the premise that family characteristics strongly influence children's health insurance coverage. Most of the independent variables were structured to reflect this focus on the family by including, where relevant, information that characterizes the family as well as the child. Health Insurance Status A child's health insurance coverage is for the previous calendar year. The March 1996 CPS asked respondents about health insurance coverage for each family member during the previous calendar year. Children insured by any source at any time during 1995 were counted as insured, and those with no reported coverage of any kind during the year were categorized as uninsured. Immigration and Citizenship Status We classified children into three immigration and citizenship categories: (1) noncitizen immigrant child—that is, a child who was not born in the United States and is not a U.S. citizen; (2) U.S. citizen child in an immigrant family—that is, a child who is a citizen (U.S. born or naturalized) and has one or more parents who are foreign born, regardless of whether they are U.S. citizens; and (3) U.S. citizen child with both parents born in the United States (or, in a single-parent family, the one parent being U.S. born). Children who were born outside the United States to U.S.-born parents are counted as U.S. born. Noncitizen immigrant children and U.S. citizen children in immigrant families were further classified by the year in which the parent who is the primary worker immigrated to the United States. Potential differences were examined among noncitizen children, citizen children in immigrant families, and children in non-immigrant families in their access to public or private health in-

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Children of Immigrants: Health, Adjustment, and Public Assistance surance coverage. First, we hypothesized that a child's citizenship status would be an important influence on whether he or she received private health insurance or Medicaid coverage. Although legal immigrants, regardless of citizenship status, were entitled to Medicaid in 1995, we anticipated that noncitizen children may have less access to these benefits. The CPS does not distinguish between legal and undocumented immigrants; noncitizens as defined in this paper include both groups. (The CPS also does not identify respondents as refugees or asylees.) Second, we hypothesized that even among U.S. citizen children their parents' immigration status would affect the children's access to coverage. We expected that U.S. citizen children with U.S.-born parents were likely to have the best access to health insurance through employment or private purchase and, in the absence of private coverage, through Medicaid and other public programs. Families were classified as immigrant if either parent was foreign born and as U.S. born if both parents (or the one parent in a single-parent family) were born in the United States. We compared immigrant children's uninsurance rates with those of U.S.-born children, a relative standard. Ethnicity We classified children into four ethnic groups: Latinos, non-Latino whites, non-Latino blacks, and non-Latino Asians; for brevity and simplicity we use the terms ''white," "black," and "Asian" to refer to persons in these non-Latino ethnic/racial groups. Sample size limitations did not permit analyses of other racial/ethnic groupings. Family Income Related to Poverty We classified children into one of four family income groups in relation to the poverty level, a standard set annually by the federal government and based on total family income from all sources and the number of persons in the family. In 1995, the year reflected in the CPS questions on health insurance coverage, the poverty level was set at $15,569 for a family of four.

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Children of Immigrants: Health, Adjustment, and Public Assistance Family Structure We expected that single-parent families would, on average, provide fewer opportunities than two-parent families for children to receive health insurance coverage through the employment of a parent. On the other hand, children in low-income single-parent families would be more likely to qualify for Medicaid. Family Work Status We wanted to examine the effects of labor force participation and employment characteristics on children's health insurance coverage. We classified a family's working status on the basis of the adult (parent) whose labor force participation provided the best opportunity for family members to receive health insurance coverage (we sometimes call this person the "primary worker" or "primary breadwinner"). A family was classified as a "full-time, full-year employee family'' if at least one of the parents reported working for an employer at least 35 hours per week for 50 to 52 weeks in 1995; a "full-time, part-year employee family" if a parent worked for an employer full time for less than 50 weeks; a "part-time employee family" if no parent worked as a full-time employee but one worked for an employer less than 35 hours a week; a "self-employed family" if a parent was self-employed; or a "nonworking family" if no parent worked during 1995. We tied several other variables to the parent identified as the primary worker. Parent's Education Status The educational attainment of the parent who is the primary worker was used to categorize the family's education status. Country of Origin We examined differences in health insurance coverage by the nativity of the child if the child is an immigrant or the parent who is the primary worker if the child is U.S. born.

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Children of Immigrants: Health, Adjustment, and Public Assistance State of Residence We examined the influence of a child's state of residence on differences in health insurance coverage. Health Status The child's general health status is based on the parent's report of the child as being in excellent, very good, good, fair, or poor health. Perceived general health status is a widely used measure in health services research; no other measures of health status are available in the CPS. Because the great majority of children are reported to be in excellent or very good health, we dichotomized this variable for children into excellent/very good and good/fair/poor. Uninsurance, Ethnicity, and Immigration and Citizenship Status Noncitizen children and citizen children in immigrant families are more likely to lack health insurance coverage than children whose parents were born in the United States (see Figure 3-1). This disparity in coverage rates by immigration and citizenship status varies by ethnicity. Asian citizen children with U.S.-born parents have the lowest uninsured rate of any group (6 percent), but Asian children in immigrant families have an uninsured rate that is more than two times that (14 percent) for children in native-born families.2 (The rate for Asian noncitizen children is not statistically different from the rate for citizen children with U.S.-born parents.) A much larger proportion of noncitizen black children are uninsured (37 percent), compared to black citizen children in immigrant families and those with U.S.-born parents (12 and 15 percent, respectively). Latino children are clearly the most disadvantaged, with the highest uninsured rates in each immigration and citizenship category, ranging from 16 percent for citizen children with U.S.-born parents to 53 percent for noncitizen 2   All references in the text to differences in proportions between groups are statistically significant (p < .05) unless otherwise stated.

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Children of Immigrants: Health, Adjustment, and Public Assistance FIGURE 3-1 Percentage uninsured by ethnicity and immigration and citizenship status, ages 0 to 17, United States, 1995. Source: March 1996 Current Population Survey. children. White children have among the lowest uninsured rates, particularly low for white noncitizen children compared to noncitizen children in the other ethnic groups. For most children, health insurance coverage is obtained through their parents' employment. In 1995, 66 percent of citizen children with U.S.-born parents were covered by one of their parent's employment-based insurance (see Table 3-1). But job-based insurance coverage varies considerably by ethnicity and immigration and citizenship status–ranging from a low of 22 percent for Latino noncitizen children to 74 percent for white U.S. citizen children with U.S.-born parents. It is striking that about two-thirds of Asian, black, and white citizen children in immigrant families have job-based health insurance, but only 35 percent of Latino children in such families do. It is also noteworthy that black and Latino citizen children with U.S.-born parents have especially low employment-based health insurance coverage rates.

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Children of Immigrants: Health, Adjustment, and Public Assistance The low rates of employment-based health insurance for some groups may be offset by higher rates of Medicaid coverage. Both black and Latino citizen children with U.S.-born parents would have even higher uninsured rates in the absence of Medicaid (Table 3-1). Within each ethnic group, much smaller percentages of noncitizen children are covered by either employment-based health insurance or Medicaid, leaving more of them uninsured. Asian and non-Latino white children have somewhat higher rates of "other" coverage, primarily privately purchased insurance. These higher rates are associated with higher family incomes and, in the case of Asian immigrant families, larger proportions engaged in self-employment, which provides fewer opportunities for employment-based health insurance coverage. Uninsured rates among children vary by social and economic factors, in addition to the large differences by ethnicity and immigration and citizenship status. Within each ethnic and immigration and citizenship status group, uninsured rates are generally higher for children whose parents had less education (see Table 3-2). Low family income is also clearly associated with higher uninsured rates, although for most groups the near poor (those with family incomes between 100 and 199 percent of poverty) have higher uninsured rates than those with incomes below poverty, reflecting the greater protection that Medicaid offers to poor children compared to those above the poverty level. Children in self-employed families clearly have the highest uninsured rates in each ethnic and immigration and citizenship status group. Ethnicity, Immigration and Citizenship Status, and Uninsurance The wide differences in uninsured rates between children in immigrant and nonimmigrant families may be due, in part, to differences between these groups in factors such as educational attainment, family work status, and family income. To better understand these relationships, we used multivariate analysis to examine the independent effects of immigration and citizenship status on the probability of being uninsured. Figure 3-2 illustrates the effects of ethnicity and immigration and citizenship status on the probability of being uninsured,

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Children of Immigrants: Health, Adjustment, and Public Assistance TABLE 3-1 Health Insurance Coverage of Children by Ethnicity and Immigration and Citizenship Status, Ages 0 to 17, United States, 1995   Uninsured (%) Employment-Based Insurance (%) Medicaid (%) Otherc (%) Total All Childrena   Citizen child with U.S.-born parents 11 66 17 6 100 (N = 58,300,000) Citizen child in Immigrant family 21 52 23 5 100 (N = 9,622,000) Noncitizen child 36 35 23 6 100 (N = 2,341,000) Asianb   Citizen child with U.S.-born parents 6 69 12 12 100 (N = 474,000) Citizen child in Immigrant family 14 66 13 7 100 (N = 1,774,000) Noncitizen child 20 45 26 9 100 (N = 607,000) Blackb   Citizen child with U.S.-born parents 15 42 40 4 100 (N = 10, 180,000)

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Children of Immigrants: Health, Adjustment, and Public Assistance ferences were found among the states. U.S.-born Latino children with immigrant parents in Texas had a much lower probability of a doctor visit if they were uninsured and had no usual source of care (57 percent) than if they had both Medicaid and a usual source of care (90 percent). Children in California, Florida, and Illinois all had similar probabilities of a doctor visit if they were uninsured and without a regular source (65 to 67 percent) and if they were covered by Medicaid and had a regular source (93 percent). Children in New Jersey and New York fared better still: 74 and 79 percent probability, respectively, if uninsured and no regular source of care and a 95 to 96 percent probability if on Medicaid with a regular source. DISCUSSION AND POLICY IMPLICATIONS Being a noncitizen or having immigrant parents puts a child at greater risk of being uninsured than are citizen children in native-born families. This risk is substantial even controlling for parents' education and the duration of parents' residence in the United States, as well as core determinants of uninsurance. The risk is greatest for noncitizen children, regardless of ethnicity. U.S. citizen children with immigrant parents also bear a greater risk of uninsurance than do those with U.S.-born parents. If the primary working parent has lived in the United States for more than 10 years, the probability of uninsurance appears to be reduced, lending some support to arguments that the longer immigrants reside here the more similar they become to the native-born population. But having parents who have resided in this country for more than 10 years does not appear to protect noncitizen white, black, or Asian children. This suggests either that they face barriers to obtaining health insurance beyond those experienced by the native-born population or those who have become citizens, or that public policy or other factors intervene for more recent arrivals to decrease their risks of uninsurance. Uninsured rates are higher among children in immigrant families from Korea and Central America than for those from other regions. Policies that extend Medicaid to refugees seem to protect children in immigrant families from Southeast Asia (specifically Vietnam, Cambodia, and Laos) from even the native-born

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Children of Immigrants: Health, Adjustment, and Public Assistance population's risk of uninsurance. State Medicaid policies also seem to have a substantial effect on uninsurance among children across all ethnic, immigration, and citizenship groups. Irrespective of ethnicity or immigration status, the unaffordability of health insurance coverage is the main reason for being uninsured. The combination of unaffordability and job-related reasons for uninsurance (e.g., employer does not offer it, job layoff, unemployment) underscores the weaknesses in this country's voluntary patchwork system of financing health insurance coverage. These problems particularly affect immigrants who come to the United States without the educational attainment needed to obtain jobs that could enable them and their families to live well above the poverty line. Children in immigrant families from Central America or some Asian countries experience greater risks of lack of insurance coverage. These risks seem not to be explained by educational attainment or living longer in the United States, suggesting that other barriers play an important role. It is noteworthy that Latino children, regardless of their own or their family's immigration and citizenship status, are at greater risk of uninsurance, even controlling for educational attainment, family work status, and family income. We should underscore the findings of this study that, even when immigrant parents work full time for the full year as employees, their children are more likely to be uninsured than are children in nonimmigrant families—and for some groups these increased risks are substantial. Immigrant children and, to a lesser extent, U.S.-born children with immigrant parents are more likely to experience problems accessing health care services than are nonimmigrant children. Immigrant children are less likely to have a usual provider or source of care than are nonimmigrant children. This was seen for each ethnic group examined—Asian, black, Latino, and white. Also, U.S.-born Latino children with immigrant parents are less likely to have a usual provider or source of care. A usual provider or source of care is an important link to the health care system and is especially critical for children because they require ongoing preventive care and monitoring of their growth and emotional and social development. Even though health insurance coverage is an important determinant of having a usual source of care, it

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Children of Immigrants: Health, Adjustment, and Public Assistance alone does not provide this important link. Other factors, such as culturally and geographically accessible services, are required. Immigrant children overall are less likely than nonimmigrant children to have had even one physician visit in the past year. Asian children in immigrant families experience the lowest probability of a physician visit of any ethnic group, followed by Latino children in immigrant families. Having a usual source of care and health insurance coverage greatly reduces the disadvantage, but Asian children remain less likely to have had the recommended number of physician visits even after accounting for these factors. Thus, even controlling for educational attainment and duration of residence in the United States, as well as for age, gender, family work status, and family income, substantial disparities in uninsurance remain between noncitizen immigrant children and citizen children with native-born parents. Citizen children with immigrant parents experience less risk, particularly if their primary working parent has lived in this country for at least 10 years. Citizenship appears to reduce but not eliminate children's risk of being uninsured. Similar disparities are found between immigrant and nonimmigrant children in access to health care services, although we could not include any measures of citizenship in our analysis because none are available in the NHIS. (The absence of adequate information on countries of origin and any information on citizenship status in the NHIS is a severe limitation for policy research on immigration.) The findings of this study underscore the importance of policies that extend health insurance coverage and improve the availability and accessibility of health care services to immigrant and nonimmigrant populations—policies that reduce the obstacles to immigrant children obtaining health care. Simply living longer in the United States or getting more education will not, by themselves, remove disparities in health insurance coverage or access to services. A variety of public policies have been established to reduce barriers to health insurance coverage and health care services. Legal immigrants were entitled to Medicaid when these surveys were conducted, and two states—New York and Florida—operated state-funded non-Medicaid health insurance programs for

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Children of Immigrants: Health, Adjustment, and Public Assistance children. In addition, federal, state, and local governments have helped to support community and migrant health centers to meet the needs of low-income communities, including those with large concentrations of immigrants. These efforts to improve access were adopted because of widespread beliefs that good access to health care promotes educational achievement and economic opportunity for children and their families. Our study demonstrates the importance of programs and policies for assuring health insurance coverage and access to health care services for immigrant children. It will be important to study the relative effectiveness of Medicaid compared with state-funded non-Medicaid programs to assure health insurance coverage for children in immigrant families and to study the contributions of a variety of programs designed to enhance access to health care services. Recent policy changes, however, are likely to weaken these existing public policies that ameliorate structural barriers to access in the health care system. The Personal Responsibility and Work Opportunity Reconciliation Act of 1996 terminated Medicaid eligibility for most new legal immigrants and, at state option, for legal immigrants who resided in the United States when the legislation was enacted on August 22, 1996. U.S. citizen children in immigrant families will continue to be eligible for Medicaid, and children who are noncitizen legal immigrants already residing in this country when the legislation was enacted will not lose their Medicaid entitlement if their states opt to continue to cover them. But children who immigrate legally to the United States after August 22, 1996, will not be eligible for nonemergency Medicaid unless their families are refugees or asylees (and then for only five years). These policy changes thus may increase uninsurance among immigrant children. The effects of these policies may be at least partially offset by the State Children's Health Insurance Program, created by the federal Balanced Budget Act of 1997, if states make noncitizen children eligible for these programs. Uninsured low-income immigrant children and nonimmigrant children in immigrant families may experience further reductions in their access to health care services if funds are reduced for community health centers and other programs that finance services for low-income persons. These changes are likely to have a cumulative adverse

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Children of Immigrants: Health, Adjustment, and Public Assistance effect on the health of immigrant children and even U.S. citizen children in immigrant families. REFERENCES Aday, L.A., C.E. Begley, D.R. Lairson, and C.H. Slater 1993 Evaluating the Health Care System: Effectiveness, Efficiency and Equity. Ann Arbor, Mich: Health Administration Press. American Academy of Pediatrics 1995 Recommendations for preventive pediatric health care. Pediatrics 96(2):712. Andersen, R.M., and E.L. Davidson 1996 Measuring access and trends. Pp. 13-40 in Changing the U.S. Health Care System. San Francisco: Jossey-Bass. Bean, F.D., J. Chapa, R.R. Berg, and K.A. Sowards 1994 Educational and sociodemographic incorporation among Hispanic immigrants to the United States. Pp. 73-100 in Immigration and Ethnicity: The Integration of America's Newest Arrivals, B. Edmonston and J. Passel, eds. Washington, D.C.: The Urban Institute Press. Berk, M.L., C.L. Schur, and J.C. Cantor 1995 Ability to obtain health care: Recent estimates from the Robert Wood Johnson Foundation National Access to Care Survey. Health Affairs 14(3):139-146. Board on Children and Families 1995 Immigrant children and their families: Issues for research and policy. The Future of Children: Critical Issues for Children and Youth 5(2):72-89. Brown, E.R. 1989 Access to health insurance in the United States. Medical Care Review 46(4):349-385. Center on Budget and Policy Priorities 1997 Medicaid Income Eligibility Guidelines for Children. Washington, D.C.: Center on Budget and Policy Priorities. Clark, R.L., J.S. Passel, W.N. Zimmerman, and M.E. Fix 1994 Fiscal Impacts of Undocumented Aliens: Selected Estimates for Seven States. Washington, D.C.: The Urban Institute. Edmonston, B., ed. 1996 Statistics on U.S. Immigration: An Assessment of Data Needs for Future Research. Committee on National Statistics. Washington, D.C.: National Academy Press. Fix, M., and J. Passel 1994 Immigration and Immigrants: Setting the Record Straight. Washington, D.C.: The Urban Institute Press. Kaiser Family Foundation 1997 http://www.kff.org/state_health, accessed 9/14/97.

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Children of Immigrants: Health, Adjustment, and Public Assistance Lee, S.M., and B. Edmonston 1994 The socioeconomic status and integration of Asian immigrants. Pp. 101-138 in Immigration and Ethnicity: The Integration of America's Newest Arrivals, B. Edmonston and J. Passel, eds. Washington, D.C.: The Urban Institute Press. Lieu, T.A., P.W. Newacheck, and M.A. McManus 1993 Race, ethnicity, and access to ambulatory care among U.S. adolescents. American Journal of Public Health 83(7):960-965. Mendoza, E.S. 1994 The health of Latino children in the United States. The Future of Children: Critical Issues for Children and Youth 4(3):43-72. Newacheck, P.W., D.C. Hughes, and J.J. Stoddard 1996 Children's access to primary care: Differences by race, income, and insurance status. Pediatrics 7(1):26-32. Stoddard, J., R. St. Peter, and P. Newacheck 1994 Health insurance status and ambulatory care in children. New England Journal of Medicine 330:1421-1425. Thamer, M., C. Richard, A.W. Casebeer, and N.F. Ray 1997 Health insurance coverage among foreign-born U.S. residents: The impact of race, ethnicity, and length of residence. American Journal of Public Health 87(1):96-102. U.S. Bureau of Labor Statistics 1997 Website: ftp://stats.bls.gov/pub/news.release/srgune.txt, accessed 8/12/97. U.S. General Accounting Office 1995 Illegal Aliens: National Net Cost Estimates Vary Widely. GAO/HEHS-95-133. Washington, D.C.: U.S. General Accounting Office. Valdez, R.B., H. Morgenstern, E.R. Brown, R. Wyn, C. Wang, and W. Cumberland 1993 Insuring Latinos against the costs of illness. Journal of the American Medical Association 269:889-894. Vega, W.A., and H. Amaro 1994 Latino outlook: Good health, uncertain prognosis. Annual Review of Public Health 15:39-67. Valdez, R.B., and G. Dallek 1991 Does the Health System Serve Black and Latino Communities in Los Angeles County? Claremont, Calif.: Tomas Rivera Center. Wood, D.L., R.A. Hayward, C.R. Corey, H.E. Freeman, and M.E Shapiro 1990 Access to medical care for children and adolescents in the United States. Pediatrics 86(5):666-673. Wyn, R., E.R. Brown, R.B. Valdez, H. Yu, W. Cumberland, H. Morgenstern, C. Hafner-Eaton, and C. Wang 1993 Health Insurance Coverage of California's Latino Population and Their Use of Health Services. Berkeley: California Policy Seminar, University of California .

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Children of Immigrants: Health, Adjustment, and Public Assistance APPENDIX 3A: VARIABLES USED IN ANALYSIS OF HEALTH INSURANCE COVERAGE We used data on children and their families from the March 1996 Current Population Survey (CPS) to examine health insurance coverage. Outcome Variable Health Insurance Status The child's health insurance coverage was the outcome variable in this portion of the study. The March CPS asks respondents about health insurance coverage for each family member during the previous calendar year. Children insured by any source at any time during 1995 were counted as insured. Because a person may have multiple sources of coverage reported for 1995, a single hierarchical variable was created to reflect rank ordering of reported health insurance coverage. We counted persons who reported having coverage through their own or a family member's employment at any time during 1995 as covered by employment-based health insurance. Children who did not have any private coverage but who had Medicaid coverage at any time during the year were counted as having coverage through that federal-state program. Persons who had other public coverage or privately purchased health insurance (i.e., not obtained through employment) were counted as ''other coverage." Those with no reported coverage of any kind during the year were categorized as "uninsured." Independent Variables Immigration and Citizenship Status We classified children into three immigration and citizenship categories: (1) noncitizen immigrant child—that is, a child who was not born in the United States and is not a U.S. citizen; (2) U.S. citizen child in an immigrant family—that is, a child who is a

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Children of Immigrants: Health, Adjustment, and Public Assistance citizen (U.S. born or naturalized) and has one or more parents who are foreign born, regardless of whether they are U.S. citizens; and (3) U.S. citizen child with both parents born in the United States (or, in a single-parent family, one U.S.-born parent). Children who were born outside the United States to U.S.-born parents are counted as U.S. born. We classified families as immigrant if either parent was foreign born and as U.S. born if both parents (or the one parent in a single-parent family) were born in the United States. We further classified groups 1 and 2 above by the duration of residence in the United States, measured by the year in which the parent who is the primary worker immigrated to this country. Ethnicity We classified a child's ethnicity based on parent-reported race and ethnic information for the child. Children were categorized into four ethnic groups: Latinos are individuals of any race who identify themselves as Hispanics of American origin (Mexican, Puerto Rican, Cuban, Central or South American). Non-Latino whites, non-Latino blacks, and non-Latino Asians were categorized according to parent-identified race. Sample size limitations did not permit analyses of other racial/ethnic groupings. Family Income Related to Poverty Children were classified into one of four poverty-level groups based on family income measured in relation to the federal poverty level. The groupings used to classify children were below poverty (i.e., less than 100 percent of the federal poverty level), 100 to 199 percent of poverty, 200 to 299 percent of poverty, and 300+ percent of poverty. In 1995, the year reflected in the CPS questions on health insurance coverage, the poverty level was set at $15,569 for a family of four. Family Structure We categorized a child as living in a two-parent or a single-parent family.

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Children of Immigrants: Health, Adjustment, and Public Assistance Family Work Status A family was classified as a "full-time, full-year employee family" if at least one of the parents reported working for an employer at least 35 hours per week for 50 to 52 weeks in 1995, as a "full-time, part-year employee family" if a parent worked for an employer full time for less than 50 weeks, as a "part-time employee family" if no parent worked as a full-time employee but one worked for an employer less than 35 hours a week, as "self-employed" if a parent was self-employed, or as "nonworking'' if no parent worked during 1995. In the regression models we combined "full-time, part-year" and "part-time" employee families into "other employee." Parent's Education Status The educational attainment of the parent whose employment characterizes the family's work status (the primary worker) was used to categorize the family's education status. Country of Origin We categorized children by the nativity of the child if the child is an immigrant or the parent who is the primary worker if the child is U.S. born. State of Residence The child's state of residence is the residence at the time of the interview. Variables Used in Analysis of Reasons for Uninsurance, Health Care Access, and Use of Health Care Services We used data from the 1994 National Health Interview Survey (NHIS) to study reasons for uninsurance among uninsured children, whether a child has a usual source of care, and a child's use of health care services. Variables in the NHIS that are similar to those available in the CPS require no further definition, but we

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Children of Immigrants: Health, Adjustment, and Public Assistance describe those that differ from the CPS variables discussed earlier. Outcome Variables Physician Visits Information on physician visits was obtained using the following NHIS question: "During the past 12 months, about how many times did (child's name) see or talk to a medical doctor or assistant?" For infants and toddlers ages 0 through 24 months we examined the probability of no use versus three or more visits per year, and for children and adolescents over 24 months through age 17 we examined no use during the past year compared with at least one visit. These criteria follow the visit schedule recommended by the American Academy of Pediatrics for preventive care and immunizations. Usual Person or Source of Care Information on whether or not a child has a usual person or place for medical care was based on the NHIS question: "Is there a particular person or place that (child's name) usually goes to when sick or needs advice about health?" This includes those with one or more usual sources of care and a small number who use a hospital emergency room as a usual source of care. Having a usual source of care has been demonstrated to be a robust measure of access to health care services. We therefore used usual source of care as an outcome variable but also as a predictor of use of physicians' services. Independent Variables Immigrant Status We classified children into three immigrant groups based on the immigrant status of the child and for U.S.-born children the immigrant status of the parents: (1) immigrant child—that is, a child not born in the United States; (2) U.S.-born child of immi-

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Children of Immigrants: Health, Adjustment, and Public Assistance grant parents—that is, a child born in the United States who has at least one immigrant parent; and (3) nonimmigrant child—that is, a U.S.-born child with U.S.-born parents (or in a single-parent family one U.S.-born parent). The NHIS does not include any questions about citizenship status. Educational Status The educational attainment of the mother was used to characterize the family's educational status. In single-father families the father's educational level was used. Health Status Two measures of health status based on parents' reports were used to measure children's health. General health status was measured as excellent, very good, good, fair, and poor and was recorded as good to excellent health and poor or fair. Activity limitations were measured as being unable to perform major activity, limited in kind/amount of activity, limited in other activity, or not limited and were recorded to reflect children with any limitation and those with no limitations. Reason for Lack of Coverage This information was based on two questions in the NHIS. The first asks respondents which of a series of statements describes why their child is not covered by any health insurance coverage. The second question asks what the main reason is for lack of coverage.