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Children of Immigrants: Health, Adjustment, and Public Assistance (1999)

Chapter: 3 Access to Health Insurace and Health Care for Children in Immigrant Families

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Suggested Citation:"3 Access to Health Insurace and Health Care for Children in Immigrant Families." National Research Council. 1999. Children of Immigrants: Health, Adjustment, and Public Assistance. Washington, DC: The National Academies Press. doi: 10.17226/9592.
×

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.

Suggested Citation:"3 Access to Health Insurace and Health Care for Children in Immigrant Families." National Research Council. 1999. Children of Immigrants: Health, Adjustment, and Public Assistance. Washington, DC: The National Academies Press. doi: 10.17226/9592.
×

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;

Suggested Citation:"3 Access to Health Insurace and Health Care for Children in Immigrant Families." National Research Council. 1999. Children of Immigrants: Health, Adjustment, and Public Assistance. Washington, DC: The National Academies Press. doi: 10.17226/9592.
×

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

Suggested Citation:"3 Access to Health Insurace and Health Care for Children in Immigrant Families." National Research Council. 1999. Children of Immigrants: Health, Adjustment, and Public Assistance. Washington, DC: The National Academies Press. doi: 10.17226/9592.
×

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

Suggested Citation:"3 Access to Health Insurace and Health Care for Children in Immigrant Families." National Research Council. 1999. Children of Immigrants: Health, Adjustment, and Public Assistance. Washington, DC: The National Academies Press. doi: 10.17226/9592.
×

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-

Suggested Citation:"3 Access to Health Insurace and Health Care for Children in Immigrant Families." National Research Council. 1999. Children of Immigrants: Health, Adjustment, and Public Assistance. Washington, DC: The National Academies Press. doi: 10.17226/9592.
×

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.

Suggested Citation:"3 Access to Health Insurace and Health Care for Children in Immigrant Families." National Research Council. 1999. Children of Immigrants: Health, Adjustment, and Public Assistance. Washington, DC: The National Academies Press. doi: 10.17226/9592.
×
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.

Suggested Citation:"3 Access to Health Insurace and Health Care for Children in Immigrant Families." National Research Council. 1999. Children of Immigrants: Health, Adjustment, and Public Assistance. Washington, DC: The National Academies Press. doi: 10.17226/9592.
×
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.

Suggested Citation:"3 Access to Health Insurace and Health Care for Children in Immigrant Families." National Research Council. 1999. Children of Immigrants: Health, Adjustment, and Public Assistance. Washington, DC: The National Academies Press. doi: 10.17226/9592.
×

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.

Suggested Citation:"3 Access to Health Insurace and Health Care for Children in Immigrant Families." National Research Council. 1999. Children of Immigrants: Health, Adjustment, and Public Assistance. Washington, DC: The National Academies Press. doi: 10.17226/9592.
×

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,

Suggested Citation:"3 Access to Health Insurace and Health Care for Children in Immigrant Families." National Research Council. 1999. Children of Immigrants: Health, Adjustment, and Public Assistance. Washington, DC: The National Academies Press. doi: 10.17226/9592.
×

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)

Suggested Citation:"3 Access to Health Insurace and Health Care for Children in Immigrant Families." National Research Council. 1999. Children of Immigrants: Health, Adjustment, and Public Assistance. Washington, DC: The National Academies Press. doi: 10.17226/9592.
×

 

Uninsured (%)

Employment-Based Insurance (%)

Medicaid (%)

Otherc (%)

Total

Citizen child in immigrant family

12

69

17

3

100

(N = 709,000)

Noncitizen child

37

40

17

6

100

(N = 181,000)

Latinob

 

Citizen child with U.S.-born parents

16

45

36

3

100

(N = 3,704,000)

Citizen child in immigrant family

29

35

34

2

100

(N = 4,638,000)

Noncitizen child

53

22

22

3

100

(N = 1,149,000)

Whiteb

 

Citizen child with U.S.-born parents

10

74

10

7

100

(N = 43,210,000)

Citizen child in immigrant family

13

68

12

7

100

(N = 2,465,000)

Noncitizen child

14

53

23

10

100

(N = 400,000)

a Includes individuals with "other race/ethnicity."

b "Latino" includes all Hispanic persons from the Americas. "Asian," "black," and "white'' do not include any persons of Latino heritage.

c "Other" includes privately purchased health insurance, Medicare, and other public programs.

SOURCE: March 1996 Current Population Survey.

Suggested Citation:"3 Access to Health Insurace and Health Care for Children in Immigrant Families." National Research Council. 1999. Children of Immigrants: Health, Adjustment, and Public Assistance. Washington, DC: The National Academies Press. doi: 10.17226/9592.
×

TABLE 3-2 Percentage of Children Uninsured by Sociodemographic Characteristics, Ethnicity, and migration and Citizenship Status, Ages 0 to 17, United States, 1995

 

Latino (any race)

 

Noncitizen Child

Citizen Child in Immigrant Family

Citizen Child in U.S.-Born Family

All Children in Group

53

(47.8,58.0)

29

(27.6,31.1)

16

(11.2,19.3)

Age

 

0-2

50

(24.1,76.2)

25

(20.8,29.7)

15

(10.6,19.6)

3-5

50

(32.0,68.2)

28

(23.4,33.0)

12

(7.9,16.7)

6-11

52

(43.4,59.7)

30

(25.6,34.1)

15

(11.4,18.5)

12-17

54

(46.9,61.5)

32

(26.7,36.7)

20

(15.5,24.0)

Family Structure

 

Married couple with children

53

(47.3,59.1)

31

(27.8,33.2)

16

(13.4,19.4)

Single adult with children

51

(40.7,61.3)

23

(18.7,27.5)

15

(12.4,18.2)

Family Income

 

Below poverty

59

(52.1,66.2)

27

(22.9,30.3)

17

(13.9,20.7)

100-199% of poverty level

47

(39.0,55.7)

37

(33.0,41.0)

21

(16.6,25.8)

200-299% of poverty level

53

(35.6,71.4)

23

(17.4,28.7)

17

(11.1,21.9)

300%+ of poverty level

16

(0,35.7)

13

(7.4,18.4)

5

(2.2,7.9)

Suggested Citation:"3 Access to Health Insurace and Health Care for Children in Immigrant Families." National Research Council. 1999. Children of Immigrants: Health, Adjustment, and Public Assistance. Washington, DC: The National Academies Press. doi: 10.17226/9592.
×

 

Asian (non-Latino)

 

Noncitizen Child

Citizen Child in Immigrant Family

Citizen Child in U.S.-Born Family

All Children in Group

20

(18.1,23.0)

14

(10.2,19.1)

6

(2.4,10.8)

Age

 

0-2

35

(2.8,67.6)

19

(11.8,25.3)

a

3-5

17

(1.3,32.6)

13

(7.0,18.2)

9

(0,21.1)

6-11

17

(7.8,25.3)

11

(6.7,16.1 )

8

(0.4,16.3)

12-17

22

(14.1,30.0)

13

(7.8,18.5)

6

(0,12.5)

Family Structure

 

Married couple with children

17

(11.3,22.4)

14

(10.6,16.5)

4

(0.1,7.4)

Single adult with children

41

(22.9,59.4)

15

(6.6,22.8)

11

(2.5,19.0)

Family Income

 

Below poverty

17

(7.5,27.4)

17

(9.4,24.4)

11

(0,22.8)

100-199% of poverty level

29

(18.0,41.0)

26

(18.1,34.0)

5

(0,14.0)

200-299% of poverty level

30

(13.3,46.6)

17

(9.6,23.5)

15

(0,32.7)

300%+ of poverty level

8

(1.1,15.2)

6

(3.1,8.7)

3

(0,7.0)

Suggested Citation:"3 Access to Health Insurace and Health Care for Children in Immigrant Families." National Research Council. 1999. Children of Immigrants: Health, Adjustment, and Public Assistance. Washington, DC: The National Academies Press. doi: 10.17226/9592.
×

 

Latino (any race)

 

Noncitizen Child

Citizen Child in Immigrant Family

Citizen Child in U.S.-Born Family

Family Work Status

 

Full-time, full-year employee

55

(48.3,61.4)

31

(27.6,33.6)

15

(12.1,17.7)

Full-time, part-year employee

46

(34.1,57.2)

28

(22.2,33.2)

25

(17.1,31.9)

Part-time employee

64

(44.8,83.8)

23

(13.9,32.6)

20

(12.0,27.5)

Self-employed

79

(54.8,102.9)

55

(42.7,66.7)

60

(37.0,82.4)

Nonworking family

39

(24.0,54.3)

13

(7.9,18.1)

10

(6.8,13.6)

Education Status of Parent

 

Less than 12 years

56

(50.2,61.9)

32

(29.4,35.5)

17

(13.4,20.7)

High school graduate

48

(34.6,61.8)

24

(19.2,28.9)

19

(15.3,22.9)

At least some college

34

(18.7,49.0)

22

(17.1,26.8)

11

(7.8,14.2)

Duration of Residence in U.S. of Parentb

 

Pre-1970-1979

47

(36.3,63.0)

27

(23.0,30.3)

N.A.

1980-1983

52

(40.5,67.6)

30

(25.7,38.1)

N.A.

1984-1989

51

(38.1,56.1)

34

(28.0,40.0)

N.A.

1990-1996

57

(46.4,67.6)

28

(12.0,31.2)

N.A.

Suggested Citation:"3 Access to Health Insurace and Health Care for Children in Immigrant Families." National Research Council. 1999. Children of Immigrants: Health, Adjustment, and Public Assistance. Washington, DC: The National Academies Press. doi: 10.17226/9592.
×

 

Asian (non-Latino)

 

Noncitizen Child

Citizen Child in Immigrant Family

Citizen Child in U.S.-Born Family

Family Work Status

 

Full-time, full-year employee

22

(14.2,30.1)

11

(8.0,13.8)

5

(1.1,9.6)

Full-time, part-year employee

20

(5.2,35.7)

27

(10.5,43.2)

7

(0,20.9)

Part-time employee

20

(1.9,39.1)

26

(10.7,40.6)

10

(0,22.6)

Self-employed

40

(0,80.3)

43

(25.0,61.7)

10

(0,33.6)

Nonworking family

13

(3.8,22.9)

8

(1.0,14.3)

4

(0,15.7)

Education Status of Parent

 

Less than 12 years

12 (3.8,19.2)

13

(6.9,19.6)

a

High school graduate

38

(17.8,57.9)

23

(15.2,30.1)

6

(0,12.4)

At least some college

22

(14.1,29.2)

11

(7.6,14.0)

7

(2.0,11.8)

Duration of Residence in U.S. of Parentb

 

Pre-1970-1979

23

(0,58.5)

10

(4.5,13.3)

N.A.

1980-1983

14

(0,28.3)

18

(11.0,31.4)

N.A.

1984-1989

20

(8.6,30.9)

16

(7.4,24.4)

N.A.

1990-1996

22

(13.0,31.0)

18

(0,26.4)

N.A.

Suggested Citation:"3 Access to Health Insurace and Health Care for Children in Immigrant Families." National Research Council. 1999. Children of Immigrants: Health, Adjustment, and Public Assistance. Washington, DC: The National Academies Press. doi: 10.17226/9592.
×

 

Latino (any race)

 

Noncitizen Child

Citizen Child in Immigrant Family

Citizen Child in U.S.-Born Family

State of Residence in the U.S.b

 

California

51

(44.0,56.7)

28

(25.2,30.5)

14

(10.3,17.2)

Florida

40

(25.8,53.0)

28

(21.1,34.8)

17

(8.9,24.5)

Illinois

45

(18.1,70.3)

25

(15.1,35.1)

13

(4.6,20.6)

New Jersey

57

(30.3,83.5)

17

(6.8,26.9)

14

(5.8,21.6)

New York

46

(29.6,61.4)

21

(12.9,29.5)

10

(5.7,14.6)

Texas

58

(47.8,67.5)

38

(32.0,42.8)

26

(22.5,29.7)

Other 44 states and District of Columbia

60

(50.6,70.3)

31

(25.1,37.2)

18

(14.1,20.8)

Suggested Citation:"3 Access to Health Insurace and Health Care for Children in Immigrant Families." National Research Council. 1999. Children of Immigrants: Health, Adjustment, and Public Assistance. Washington, DC: The National Academies Press. doi: 10.17226/9592.
×

 

Asian (non-Latino)

 

Noncitizen Child

Citizen Child in Immigrant Family

Citizen Child in U.S.-Born Family

State of Residence in the U.S.b

 

California

15

(8.2,21.0)

13

(8.9,16.5)

9

(0,17.3)

Florida

28

(0.7,54.9)

4

(0,11.7)

a

Illinois

a

9

(0,20.5)

a

New Jersey

23

(0,49.3)

5

(0,16.0)

7

(0,16.5)

New York

39

(20.4,57.2)

19

(7.1,29.5)

18

(3.8,32.1)

Texas

27

(0,59.0)

25

(11.6,37.6)

15

(2.2,27.2)

Other 44 states and District of Columbia

28

(17.1,37.4)

13

(7.1,19.1)

10

(4.7,13.8)

Suggested Citation:"3 Access to Health Insurace and Health Care for Children in Immigrant Families." National Research Council. 1999. Children of Immigrants: Health, Adjustment, and Public Assistance. Washington, DC: The National Academies Press. doi: 10.17226/9592.
×

 

African American (non-Latino)

 

Noncitizen Child

Citizen Child in Immigrant Family

Citizen Child in U.S.-Born Family

All Children in Group

37

(19.5,49.3)

12

(9.4,15.4)

15

(13.9,17.0)

Age

 

0-2

35

(0,80.9)

19

(7.1,30.6)

15

(11.9,17.9)

3-5

29

(0,65.3)

10

(1.7,19.1)

13

(10.2,15.7)

6-11

43

(19.3,67.1)

9

(2.9,16.0)

15

(12.6,16.9)

12-17

35

(18.2,51.8)

10

(2.5,17.8)

16

(13.5,18.0)

Family Structure

 

Married couple with children

34

(17.4,49.6)

6

(2.5,10.4)

15

(12.8,17.1 )

Single adult with children

41

(21.7,60.5)

22

(12.4,30.8)

15

(13.2,16.2)

Family Income

 

Below poverty

38

(17.3,59.6)

19

(9.2,28.7)

14

(11.7,15.4)

100-199% of poverty level

49

(26.3,71.5)

22

(10.3,33.1 )

20

(17.5,22.9)

200-299% of poverty level

32

(2.1,61.7)

4

(0,8.9)

13

(10.3,16.5)

300%+ of poverty level

13

(0,35.0)

3

(0,6.9)

10

(7.8,13.0)

Suggested Citation:"3 Access to Health Insurace and Health Care for Children in Immigrant Families." National Research Council. 1999. Children of Immigrants: Health, Adjustment, and Public Assistance. Washington, DC: The National Academies Press. doi: 10.17226/9592.
×

 

White (non-Latino)

 

Noncitizen Child

Citizen Child in Immigrant Family

Citizen Child in U.S.-Born Family

All Children in Group

14

(8.2,19.9)

13

(10.9,15.5)

10

(9.7,10.7)

Age

 

0-2

14

(0,41.3)

13

(7.7,18.0)

11

(9.6,12.2)

3-5

2

(0,7.0)

15

(8.9,20.4)

10

(8.6,11.0)

6-11

15

(4.7,25.7)

14

(9.7,17.5)

10

(9.3,11.0)

12-17

18

(8.2,27.6)

12

(7.7,16.2)

10

(9.3,11.0)

Family Structure

 

Married couple with children

13

(6.6,19.0)

11

(8.9,13.5)

9

(8.2,9.2)

Single adult with children

21

(3.4,37.7)

27

(18.5,35.4)

16

(14.3,16.8)

Family Income

 

Below poverty

25

(11.5,38.2)

18

(11.1,24.2)

23

(21.0,25.2)

100-199% of poverty level

14

(1.5,25.5)

31

(23.8,38.9)

18

(16.8,19.6)

200-299% of poverty level

6

(0,15.1)

12

(6.3,16.9)

9

(8.2,10.2)

300%+ of poverty level

8

(0,17.6)

6

(3.6,8.1)

4

(3.9,4.8)

Suggested Citation:"3 Access to Health Insurace and Health Care for Children in Immigrant Families." National Research Council. 1999. Children of Immigrants: Health, Adjustment, and Public Assistance. Washington, DC: The National Academies Press. doi: 10.17226/9592.
×

 

African American (non-Latino)

 

Noncitizen Child

Citizen Child in Immigrant Family

Citizen Child in U.S.-Born Family

Family Work Status

 

Full-time, full-year employee

39

(22.6,56.1)

9

(4.5,14.0)

14

(12.6,16.0)

Full-time, part-year employee

12

(0,32.8)

14

(1.8,26.0)

18

(14.0,21.3)

Part-time employee

32

(0,95.8)

25

(3.0,46.7)

18

(13.7,22.2)

Self-employed

a

44

(0,100)

55

(37.3,12.6)

Nonworking family

59

(29.9,88.2)

2

(1.2,22.5)

12

(9.5,13.8)

Education Status of Parent

 

Less than 12 years

37

(16.7,56.9)

24

(10.9,37.5)

17

(14.5,19.5)

High school graduate

51

(26.8,75.1)

20

(9.7,31.1)

16

(14.1,18.3)

At least some college

24

(5.2,43.7)

4

(0.8,7.6)

12

(9.8,13.5)

Duration of Residence in U.S. of Parentb

 

Pre-1970-1979

18

(0,39.9)

14

(9.6,23.2)

N.A.

1980-1983

17

(0,37.3)

31

(11.1,50.1)

N.A.

1984-1989

23

(3.1,45.3)

21

(11.9,35.8)

N.A.

1990-1996

33

(3.1,45.3)

14

(11.9,42.4)

N.A.

Suggested Citation:"3 Access to Health Insurace and Health Care for Children in Immigrant Families." National Research Council. 1999. Children of Immigrants: Health, Adjustment, and Public Assistance. Washington, DC: The National Academies Press. doi: 10.17226/9592.
×

 

White (non-Latino)

 

Noncitizen Child

Citizen Child in Immigrant Family

Citizen Child in U.S.-Born Family

Family Work Status

 

Full-time, full-year employee

12

(5.0,18.4)

11

(8.9,14.0)

7

(6.9,7.9)

Full-time, part-year employee

18

(0,37.1)

11

(4.0,18.0)

16

(14.2,18.2)

Part-time employee

7

(0,34.8)

14

(3.4,24.6)

19

(16.0,21.3)

Self-employed

17

(0,52.4)

40

(26.6,53.2)

30

(26.0,33.1)

Nonworking family

21

(3.9,38.1)

9

(1.4,17.6)

16

(13.0,18.4)

Education Status of parent

 

Less than 12 years

24

(8.0,39.5)

22

(14.7,28.5)

23

(21.0,25.4)

High school graduate

13

(0,26.8)

15

(9.8,19.9)

13

(11.8,13.7)

At least some college

11

(4.4,17.9)

10

(7.6,13.0)

6

(5.9,7.0)

Duration of Residence in U.S. of Parentb

 

Pre-1970-1979

17

(4.9,28.6)

12

(9.3,15.1)

N.A.

1980-1983

14

(1.4,26.5)

18

(6.8,21.9)

N.A.

1984-1989

21

(9.1,32.3)

17

(7.6,28.8)

N.A.

1990-1996

14

(11.9,18.6)

15

(5.5,19.8)

N.A.

Suggested Citation:"3 Access to Health Insurace and Health Care for Children in Immigrant Families." National Research Council. 1999. Children of Immigrants: Health, Adjustment, and Public Assistance. Washington, DC: The National Academies Press. doi: 10.17226/9592.
×

 

African American (non-Latino)

 

Noncitizen Child

Citizen Child in Immigrant Family

Citizen Child in U.S.-Born Family

State of Residence in the U.S.b

 

California

a

8

(0,21.5)

13

(8.8,16.2)

Florida

46

(24.5,67.3)

14 

16

(11.4,19.6)

Illinois

a

54

(46.6,61.1)

14

(10.1,17.7)

New Jersey

33

(0,72.4)

12

(0,25.1)

8

(2.4,12.4)

New York

24

(7.4,40.1)

23

(15.4,31.0)

13

(8.9,16.7)

Texas

12

(10.2,14.3)

28

(18.8,36.7)

22

(17.1,26.2)

Other 44 states and District of Columbia

24

(9.3,38.7)

5

(0.9,8.5)

16

(14.2,16.7)

NOTE: Numbers in parentheses are 95% confidence intervals.

a Insufficient sample data to make population estimate.

b Estimates for these variables are an average of 1995 and 1996 CPS data.

SOURCE: March 1996 Current Population Survey.

Suggested Citation:"3 Access to Health Insurace and Health Care for Children in Immigrant Families." National Research Council. 1999. Children of Immigrants: Health, Adjustment, and Public Assistance. Washington, DC: The National Academies Press. doi: 10.17226/9592.
×

 

White (non-Latino)

 

Noncitizen Child

Citizen Child in Immigrant Family

Citizen Child in U.S.-Born Family

State of Residence in the U.S.b

 

California

19

(9.6,28.1)

14

(9.6,18.1)

11

(9.4,12.6)

Florida

21

(2.4,40.1)

17

(8.1,25.7)

12

(10.1,14.3)

Illinois

7

(0,15.5)

5

(0.4,9.1)

7

(5.1,8.3)

New Jersey

17

(0,35.1)

11

(4.7,17.6)

10

(6.9,11.7)

New York

18

(5.9,28.5)

17

(11.9,21.8)

9

(6.6,9.7)

Texas

23

(0,51.0)

9

(2.4,14.7)

15

(12.7,16.8)

Other 44 states and District of Columbia

14

(7.5,21.1)

11

(8.4,13.6)

10

(9.7,10.6)

Suggested Citation:"3 Access to Health Insurace and Health Care for Children in Immigrant Families." National Research Council. 1999. Children of Immigrants: Health, Adjustment, and Public Assistance. Washington, DC: The National Academies Press. doi: 10.17226/9592.
×

FIGURE 3-2 Predicted probabilities of uninsurance by ethnicity and immigration and citizenship status, ages 3 to 5, United States, 1995. Predicted probabilities are for a female child, 3 to 5 years old, in good to excellent health, living in a two-parent family with at least one parent employed full time for the full year, a family income of 100 to 199 percent of the federal poverty level, and one parent who is a primary worker and has not graduated from high school. SOURCE: March 1996 Current Population Survey.

Suggested Citation:"3 Access to Health Insurace and Health Care for Children in Immigrant Families." National Research Council. 1999. Children of Immigrants: Health, Adjustment, and Public Assistance. Washington, DC: The National Academies Press. doi: 10.17226/9592.
×

based on our multivariate analysis. The figure shows how each combination of ethnicity and immigration and citizenship status affects the probability that a child with specific characteristics would be uninsured, holding constant factors other than ethnicity and immigration and citizenship status. We chose to illustrate the effect with a child who is female, 3 to 5 years old, in good to excellent health, living in a two-parent family in which at least one parent is employed full time for the full year, where the family income is between 100 and 199 percent of the federal poverty level, and where the parent who is the primary worker has not graduated from high school. The probabilities depicted in Figure 3-2 and discussed below are specific to this defined set of characteristics, but another set of characteristics would likely demonstrate similar relationships of ethnicity and immigration and citizenship status to the probability of uninsurance.

Immigration and citizenship status and ethnicity affect children's access to health insurance coverage. However, immigration and citizenship status affects the risk of uninsurance differently for different ethnic groups. Among Latinos with the defined characteristics, the probability of uninsurance is lowest for those with both parents born in the United States (24 percent; Figure 3-2 and Table 3-3). It is substantially greater among those children who are citizens but have at least one parent who is an immigrant and greater among those in this group whose parents immigrated to the United States in 1984 or later (37 percent) than for those whose families came earlier (32 percent). The probability of uninsurance is considerably greater still for noncitizen children, particularly those whose parents arrived in the United States in 1984 or later (58 percent). It is worth emphasizing that all of the children in this profile, including those whose probability of being uninsured reaches or exceeds 50 percent, are in families headed by a full-time full-year employee.

Among Asian children with the defined characteristics, the probability of uninsurance is similarly greater among those who are citizens in immigrant families than among children with U.S.-born parents, and it is greater still for noncitizen children. Citizen children with immigrant parents who arrived before 1984 have a lower probability of uninsurance than those who arrived more recently, but the relationship is reversed among noncitizen Asian

Suggested Citation:"3 Access to Health Insurace and Health Care for Children in Immigrant Families." National Research Council. 1999. Children of Immigrants: Health, Adjustment, and Public Assistance. Washington, DC: The National Academies Press. doi: 10.17226/9592.
×

TABLE 3-3 Predicted Probabilities of Uninsurance by Ethnicity and Immigration and Citizenship Status, Ages 3 to 5, United States, 1995 a

 

White (%)

Latino (%)

Black (%)

Asian (%)

Child with U.S.-born parents

20

24

22

13

Citizen child, immigrant family

Came to U.S. before 1984

25

32

21

24

Came to U.S. in 1984 or later

32

37

28

32

Noncitizen child

Came to U.S. before 1984

32

50

54

38

Came to U.S. in 1984 or later

24

58

42

34

a Predicted probabilities are for a female child, 3 to 5 years old, in good to excellent health, living in a two-parent family, with at least one parent employed full time for the full year, a family income of 100 to 199 percent of the federal poverty level, and one parent who is a primary worker and has not graduated from high school.

SOURCE: March 1996 Current Population Survey.

children, with more recent arrivals having a lower probability of uninsurance.

For black children the effect of immigration and citizenship status on uninsurance seems more complex. Citizen children with U.S.-born parents and those with immigrant parents all seem to cluster with probabilities of being uninsured ranging from 21 to 28 percent. Noncitizen children, on the other hand, have a very high probability of uninsurance, particularly if their families came to the United States before 1984 (54 percent). Non-Latino white children with the defined characteristics follow a pattern similar to that of black children, although noncitizen white children fare better than similar children in any other ethnic group.

It is noteworthy that, even among children whose parents are U.S. born, Latino children have a greater probability of being uninsured than do non-Latino white children. Thus, even controlling for parents' educational attainment, family work status, and poverty level, Latino children in U.S.-born families are disadvantaged relative to other comparable children in other ethnic groups. Asian children of U.S.-born parents, on the other hand, have the

Suggested Citation:"3 Access to Health Insurace and Health Care for Children in Immigrant Families." National Research Council. 1999. Children of Immigrants: Health, Adjustment, and Public Assistance. Washington, DC: The National Academies Press. doi: 10.17226/9592.
×

lowest probability of being uninsured of any ethnic/immigration group.

State of Residence and Uninsurance

The state in which a child resides has a substantial effect on his or her probability of being uninsured. To illustrate how state of residence affects these probabilities, we have chosen to compare the probability of uninsurance for an Asian child and a Latino child with the same characteristics described above. In this illustration the child is a female, 3 to 5 years old, in good to excellent health, living in a two-parent family in which at least one parent is a full-time full-year employee, whose family income is 100 to 199 percent of the poverty level, and where the primary breadwinning parent has not graduated from high school.

Within each ethnic group, citizen children in immigrant families in Texas have the highest probability of being uninsured among the states examined, followed by similar children in Florida and New Jersey (see Figure 3-3 for Latinos and Asians and Table 3-4 for all ethnic groups). Children in California and New York fare somewhat better, while those in Illinois have the lowest probability of uninsurance. In each state Latino citizen children with immigrant parents have higher probabilities of being uninsured than do similar children in other ethnic groups.

Many factors contribute to these differences among the states in the probability of being uninsured. Differences among the states in their Medicaid eligibility policies may account for part of the differences in the probability of uninsurance. The federal Medicaid program mandates states to cover all pregnant women and children under age 6 up to 133 percent of the federal poverty level, reducing disparities in Medicaid income eligibility by state. However, some states, such as California, have established state-funded Medicaid eligibility for pregnant women and infants up to 200 percent of the poverty level. Some states, including California and Texas, have not yet eliminated financial asset tests for Medicaid; these asset tests exclude some very low-income persons whose assets may exceed restrictive allowable levels. In addition, states with very low income eligibility levels for Aid to Families with Dependent Children (AFDC), such as Texas and

Suggested Citation:"3 Access to Health Insurace and Health Care for Children in Immigrant Families." National Research Council. 1999. Children of Immigrants: Health, Adjustment, and Public Assistance. Washington, DC: The National Academies Press. doi: 10.17226/9592.
×

FIGURE 3-3 Predicted probabilities of uninsurance among citizen children with immigrant parents who immigrated to the United States in 1984 or later by ethnicity and state of residence, ages 3 to 5, 1995. Predicted probabilities are for a female child, 3 to 5 years old, in good to excellent health, living in a two-parent family with at least one parent employed full time for the full year, a family income of 100 to 199 percent of the federal poverty level, and one parent who is a primary worker and has not graduated from high school. SOURCE: March 1996 Current Population Survey.

Suggested Citation:"3 Access to Health Insurace and Health Care for Children in Immigrant Families." National Research Council. 1999. Children of Immigrants: Health, Adjustment, and Public Assistance. Washington, DC: The National Academies Press. doi: 10.17226/9592.
×

TABLE 3-4 Predicted Probabilities of Uninsurance Among Citizen Children with Immigrant Parents Who Came to the United States in 1984 or Later by Ethnicity and State of Residence, Ages 3 to 5, United States, 1995a

State of Residence

White (%)

Latino (%)

Black (%)

Asian (%)

California

32

35

28

31

Florida

38

42

33

37

Illinois

26

30

23

26

New Jersey

35

39

31

34

New York

32

36

25

28

Texas

43

47

38

42

Rest of the U.S.

32

36

28

31

a Predicted probabilities for a female child, 3 to 5 years old, in good to excellent health, living in a two-parent family, with at least one parent employed full time for the full year, a family income of 100 to 199 percent of the federal poverty level, and one parent who is a primary worker and has not graduated from high school.

SOURCE: March 1996 Current Population Survey.

Florida, indirectly reduce Medicaid eligibility because AFDC conveys automatic Medicaid enrollment, which provides coverage to many children who otherwise would not be enrolled. Finally, some states, including Illinois, New York, and Texas, have short Medicaid application forms, reducing the burden on parents associated with the more typical long-form applications (Donna C. Ross, Center on Budget and Policy Priorities, personal communication, 1997). These are provisions that affect all children in a state—those in immigrant families as well as those with native-born parents—but each state may include a combination of policies that tend to increase Medicaid coverage and others that tend to reduce it. And they appear to result in differential proportions of low-income children covered by Medicaid. The proportion of all children below 150 percent of poverty who were covered by Medicaid varied from 75 percent in Illinois to 71 percent in New York to 65 percent in New Jersey and California to 58 percent in Texas and 59 percent in Florida (Kaiser Family Foundation, 1997).

Immigrant children may be particularly affected by two other

Suggested Citation:"3 Access to Health Insurace and Health Care for Children in Immigrant Families." National Research Council. 1999. Children of Immigrants: Health, Adjustment, and Public Assistance. Washington, DC: The National Academies Press. doi: 10.17226/9592.
×

policies that vary from state to state. Fear of being labeled a ''public charge" may discourage immigrant parents from enrolling their children in Medicaid, fearing that this stigma may be used against them in any future immigration proceedings. Federal implementation of the prohibition against noncitizens being a "public charge" varies from one jurisdiction to another, including from state to state. A state policy that may facilitate extending coverage to children in immigrant families, as well as other children, is the establishment of state-funded non-Medicaid children's health insurance programs. New York and Florida have substantial non-Medicaid programs that provide health insurance to children, covering immigrant children who are not eligible for Medicaid as well as those who are eligible.

In addition to differences in Medicaid eligibility and enrollment, states differ in other factors that may contribute to differences in uninsured rates. These factors include the percentages of the working-age population who are unemployed, underemployed, or working in sectors of the economy that typically provide health benefits to relatively few workers (e.g., retail, service, agriculture, construction) and the percentage of the population with family incomes below the poverty line or who are near poor. Unemployment, for example, varied considerably among the states, with California having the highest annual rate (7.8 percent) in 1995; New York, New Jersey, and Texas had intermediate rates (ranging from 6.0 to 6.4 percent); and Florida and Illinois had the lowest rates (5.5 and 5.0 percent, respectively; see U.S. Bureau of Labor Statistics, 1997). The rankings of states by unemployment rate are not consistent with the rankings by probability of uninsurance, suggesting that a state's unemployment rate may have only a weak relationship with its probability of uninsurance.

All of these factors may contribute to differences among the states in the probability of uninsurance in ways that are not specifically measured in this study. Although we cannot quantify the effects of each policy, we believe that the combination of state-level Medicaid and other policies contributes to differences among the states in rates of uninsured children.

Suggested Citation:"3 Access to Health Insurace and Health Care for Children in Immigrant Families." National Research Council. 1999. Children of Immigrants: Health, Adjustment, and Public Assistance. Washington, DC: The National Academies Press. doi: 10.17226/9592.
×

Country of Origin and Uninsurance

The differences in risk of uninsurance vary considerably by the country or region from which a child and/or immigrant parents emigrated (see Table 3-5). Approximately half of noncitizen children who were born in Cuba, Mexico, or Central America are uninsured, compared to substantially lower rates for those from other countries, perhaps reflecting the generally low educational attainment of their parents, which tends to restrict employment to jobs without health benefits. Noncitizen children from Hong Kong, Japan, Singapore, Taiwan, Europe, China, the Philippines, Malaysia, and Indonesia all rank lower in their rates of uninsurance than those from Latin American countries; for most of the children in more advantaged families, their lower uninsurance rates reflect higher rates of employment-based health insurance, which typically accrues to workers with higher levels of educational attainment. Noncitizen children from Cambodia, Laos, and Vietnam rank lowest in uninsured rates (9 percent), reflecting very high rates of Medicaid coverage (64 percent), rather than employment-based health insurance (24 percent).

Among citizen children in immigrant families, rates of uninsurance do not reach the same levels as among noncitizen children. Citizen children whose primary working parent was born in Mexico, Central America, India, Afghanistan, Bangladesh, or Pakistan have elevated rates of uninsurance (ranging from 25 to 32 percent), but those whose parents are from Korea have the highest uninsurance rate (42 percent). Controlling for immigration and citizenship status and year in which the primary working parent immigrated to the United States, as well as other predictors of insurance coverage, children whose families are from Korea are substantially more likely to be uninsured than are those with U.S.-born parents (see Table 3-6). Central American-origin children also fare more poorly compared with children with U.S.-born parents.

However, children whose families are from Cambodia, Laos, or Vietnam have a much lower risk of being uninsured than do children with U.S.-born parents. These children have a low risk of uninsurance despite the low educational attainment of their

Suggested Citation:"3 Access to Health Insurace and Health Care for Children in Immigrant Families." National Research Council. 1999. Children of Immigrants: Health, Adjustment, and Public Assistance. Washington, DC: The National Academies Press. doi: 10.17226/9592.
×

TABLE 3-5 Percentage of Children Uninsured Among Noncitizen Children and Citizen Children in Immigrant Families by Country or Region of Origin, Ages 0 to 17, United States, 1994 and 1995 (average)

 

Noncitizen Children

Citizen Children in Immigrant Families

Country or Region of Origina

% Uninsured

Total Number of Children in Population Groupb

% Uninsured

Total Number of Children in Population Groupb

Central America

55

153,000

32

682,000

Cuba

51

30,000

17

186,000

Mexico

48

843,000

29

3,194,000

South America

39

100,000

17

372 000

Caribbean

30

139,000

18

434 000

Africa

30

50,000

2

184 000

Cambodia, Laos, and Vietnam

9

232,000

13

473 000

China

27

53,000

16

216 000

Hong Kong, Japan, Singapore, and Taiwan

16

56,000

9

123 000

India, Afghanistan, Bangladesh, and Pakistan

39

106,000

25

327 000

Korea

38

50,000

42

135 000

Philippines, Malaysia, and Indonesia

25

78,000

7

382 000

Thailand and Burma

c

6,000

c

6 000

Canada

c

14,000

8

170,000

Europe

20

225,000

14

676,000

a Nativity of child for noncitizen children and nativity of primary working parent for citizen children in immigrant families.

b Total population sizes from the March 1996 Current Population Survey.

c Indicates sample size insufficient to make reliable estimates.

SOURCE: March 1995 and 1996 Current Population Surveys.

Suggested Citation:"3 Access to Health Insurace and Health Care for Children in Immigrant Families." National Research Council. 1999. Children of Immigrants: Health, Adjustment, and Public Assistance. Washington, DC: The National Academies Press. doi: 10.17226/9592.
×

TABLE 3-6 Effect of Socioeconomic Factors, Immigration and Citizenship Status, Ethnicity, and Country of Origin on Uninsurance for Children, Ages 0 to 17, United States, 1995

Country or Region of Origin

Odds Ratio

95% Confidence Interval for Odds Ratio

Central America

1.69

1.11,2.59

Cuba

1.12

0.61,2.06

Mexico

1.19

0.81,1.76

South America

.98

0.61,1.59

Caribbean

1.50

0.79 2.88

Africa

.57

0.24 1.38

Cambodia, Laos, and Vietnam

0.27

0.14 0.52

China

1.02

0.50 2.08

Hong Kong, Singapore, Taiwan, and Japan

0.44

0.18 1.08

India, Afghanistan, Bangladesh, and Pakistan

1.28

0.71 2.31

Korea

3.40

1.65 6.98

Philippines, Malaysia, and Indonesia

.65

0.33 1.30

Thailand and Burma

2.21

0.45 10.85

Canada

1.33

0.76 2.34

Europe

0.79

0.52,1.18

NOTE: Model controls for age, gender, health status, family structure, family work status, family income, educational attainment of primary working parent, ethnicity, immigration and citizenship status, and year immigrated to the United States.

SOURCE: March 1996 Current Population Survey.

working parents (53 percent of whom have less than a high school education), low participation in the labor force (40 percent are in nonworking families), and high rates of poverty (48 percent have family incomes below the poverty line). Medicaid protects these children because federal law provides generous eligibility provisions for very low-income refugee and asylee families, although refugees and asylees who immigrated after enactment of the 1996 welfare reform legislation will be eligible for Medicaid only during their first five years in the United States.

Suggested Citation:"3 Access to Health Insurace and Health Care for Children in Immigrant Families." National Research Council. 1999. Children of Immigrants: Health, Adjustment, and Public Assistance. Washington, DC: The National Academies Press. doi: 10.17226/9592.
×

Summary

Clearly, being a noncitizen or having immigrant parents increases a child's risk of being uninsured. Immigration and citizenship status of both the child and the primary breadwinning parent (i.e., the parent whose main activity determines the family's work status) have a substantial independent effect on children's risk of uninsurance, even controlling for the parent's educational attainment and even if the parent has resided in the United States for longer than 10 years, as well as core determinants of uninsurance (such as family work status and family income).

In general, noncitizen children have the greatest risk of being uninsured. Noncitizen Latino and Asian children, regardless of when their families immigrated to the United States, have a greater probability of being uninsured compared with similar children who were born in the United States and compared with white children with U.S.-born parents. Black and white noncitizen children's excess risk appears to be related to when their families immigrated, with those who immigrated before 1984 faring worse than those whose families immigrated later.

U.S. citizen children with immigrant parents also tend to be at greater risk of uninsurance compared to those with U.S.-born parents. Moreover, citizen children in immigrant families have a greater risk of being uninsured if their families immigrated to the United States in 1984 or later than if they immigrated earlier than 1984. Even after controlling for immigration and citizenship status, year in which parents immigrated, and important predictors of health insurance coverage, Korean- and Central American-origin children are more likely to be uninsured, for reasons that are not immediately clear.

Medicaid can offer protection to immigrant families, thereby reducing the risks of uninsurance. Southeast Asian immigrant children and their families have very low rates of uninsurance despite their very low socioeconomic status because their refugee and asylee status opens the door to relatively generous Medicaid eligibility provisions. The importance of Medicaid eligibility policies and other state health insurance policies is also suggested by the differences among the U.S. states of residence, although quan-

Suggested Citation:"3 Access to Health Insurace and Health Care for Children in Immigrant Families." National Research Council. 1999. Children of Immigrants: Health, Adjustment, and Public Assistance. Washington, DC: The National Academies Press. doi: 10.17226/9592.
×

tifying the effects of specific policies is beyond the scope of this paper. Public policy can play an important role in protecting children from being uninsured.

EFFECTS OF IMMIGRATION STATUS ON ACCESS TO CARE

Are children who are immigrants disadvantaged in their access to health care services compared to U.S.-born children in native-born families? Are U.S.-born children in immigrant families disadvantaged compared to those whose parents were born in the United States? To answer these questions, we compared the health care access and use of physician services of children who are immigrants, nonimmigrant children in families with one or more immigrant parents, and nonimmigrant children with U.S.-born parents. We used data on children and their families from the 1994 NHIS.

Variables Used in Analysis of Reasons for Uninsurance, Health Care Access, and Use of Health Care Services

The NHIS includes information that is not available in the CPS, including measures of health status, reasons for uninsurance, usual source of care, and use of health care services. In addition, some variables in the CPS are not available in the NHIS. As with the analyses of health insurance coverage, we structured several independent variables to characterize the families as well as the children.

Outcome Variables

Physician Visits. The number of physician visits during the past 12 months was obtained for all children. We examined the probability of at least one physician visit during the past year for all children, newborn through age 17. The American Academy of Pediatrics recommends annual visits for children and adolescents ages 24 months through age 17 (except for children ages 7 and 9) and more frequent visits for children under 24 months of age (American Academy of Pediatrics, 1995). Thus, our criterion of at least one physician visit during the past year provides a reason-

Suggested Citation:"3 Access to Health Insurace and Health Care for Children in Immigrant Families." National Research Council. 1999. Children of Immigrants: Health, Adjustment, and Public Assistance. Washington, DC: The National Academies Press. doi: 10.17226/9592.
×

able measure of the academy's recommendation for children over the age of 24 months and is a conservative estimate for children under this age.

Usual Person or Source of Care. Information was obtained on whether or not the child has a usual person or place for medical care. Having a usual source of care has been demonstrated to be a robust measure of access to health care services. We thus used usual source of care as an outcome variable in descriptive analyses but also as a predictor in all analyses of use of physician 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 immigrant 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, a parent who is U.S. born). Children not born in the United States to U.S.-born parents were classified as nonimmigrant children. The NHIS does not include any questions about citizenship status.

Educational Status. The educational attainment of the mother was used to characterize a family's educational status because a mother's educational attainment has been shown to be related to health care use. In single-father families the father's educational level was used.

Health Status. Two measures of health status were used to measure the health of the child. General health status was defined as "good to excellent health" or "fair or poor health." Children were also classified as having any limitation (unable to perform a major activity, limited in kind/amount of activity, limited in other activity) or as not having any limitations.

Suggested Citation:"3 Access to Health Insurace and Health Care for Children in Immigrant Families." National Research Council. 1999. Children of Immigrants: Health, Adjustment, and Public Assistance. Washington, DC: The National Academies Press. doi: 10.17226/9592.
×

Reason for Lack of Coverage. We included information on why an uninsured child has no health insurance coverage.

Main Reasons for Lack of Coverage Among Children

The main reason reported (by adult respondents) for children's lack of coverage is the same regardless of immigrant status: health insurance coverage is unaffordable (see Table 3-7). Within each ethnic group, lack of affordability was the dominant reason for lack of coverage. The dominant role that affordability plays in limiting coverage highlights the need for improving the affordability of coverage through contributions from employers and/or public programs. The second most frequently cited reason for lack of coverage is related to employers not offering coverage—that is, the employer does not offer coverage at all, does not offer family coverage, or does not offer coverage to part-time employees. Job layoff or unemployment of the parent accounted for an additional, yet small, percentage of the reason for lack of coverage.

Beliefs about coverage—that it is not needed, dissatisfaction with coverage, or lack of belief in health insurance—account for an additional 5 percent of children overall, with some differences by ethnicity and immigrant status. The availability of free services or other options to obtain care explains only a small portion of uninsured children's lack of coverage. Thus, a perceived lack of need for coverage—either because of beliefs or other options for care—is not an important reason for lack of coverage for any of the immigrant groups.

Usual Person/Place of Care

Children not born in the United States are more likely to lack a usual person or place for health care (28 percent) than either U.S.-born children with immigrant parents (8 percent) or nonimmigrant children (5 percent; see Table 3-8). This large proportion of foreign-born children who lack a usual source of care is seen in each ethnic group. Latino immigrants in particular have high rates, with over one-third (36 percent) lacking a usual source of care.

Suggested Citation:"3 Access to Health Insurace and Health Care for Children in Immigrant Families." National Research Council. 1999. Children of Immigrants: Health, Adjustment, and Public Assistance. Washington, DC: The National Academies Press. doi: 10.17226/9592.
×

TABLE 3-7 Main Reasons for Lack of Coverage Among Uninsured Children by Immigration and Ethnicity, Ages 0 to 17, United States, 1994

 

Latino

 

Immigrant Child (%)

Child U.S.-Born, Immigrant Parents (%)

Child and Parents U.S. Born (%)

Too expensive

72

71

79

Employer does not offer or worker not eligible

13

12

9

Beliefs about coverage

3

5

1

Other options

4

3

1

Job layoff or unemployed

1

3

3

Other reasons

7

6

7

 

Black

 

 

Too expensive

a

a

71

Employer does not offer or worker not eligible

a

a

9

Beliefs about coverage

a

a

3

Other options

a

a

4

Job layoff or unemployed

a

a

4

Other reasons

a

a

9

a Sample size too small to make a reliable estimate.

SOURCE: 1994 National Health Interview Survey.

Suggested Citation:"3 Access to Health Insurace and Health Care for Children in Immigrant Families." National Research Council. 1999. Children of Immigrants: Health, Adjustment, and Public Assistance. Washington, DC: The National Academies Press. doi: 10.17226/9592.
×

 

Asian

 

Immigrant Child (%)

Child U.S.-Born, Immigrant Parents (%)

Child and Parents U.S. Born (%)

Too expensive

64

75

a

Employer does not offer or worker not eligible

13

5

a

Beliefs about coverage

7

<1

a

Other options

<1

<1

a

Job layoff or unemployed

9

3

a

Other reasons

7

17

a

 

White

 

 

Too expensive

68

74

76

Employer does not offer or worker not eligible

10

9

5

Beliefs about coverage

12

11

5

Other options

1

3

<1

Job layoff or unemployed

<1

2

4

Other reasons

9

<1

9

Suggested Citation:"3 Access to Health Insurace and Health Care for Children in Immigrant Families." National Research Council. 1999. Children of Immigrants: Health, Adjustment, and Public Assistance. Washington, DC: The National Academies Press. doi: 10.17226/9592.
×

TABLE 3-8 Percentage of Children with No Usual Person or Place for Medical Care and Percentage Who Did Not Have a Physician Visit During the Past Year, by Immigration Status and Ethnicity, Ages 0 to 17, United States, 1994

 

All Children

Main Reason for Lack of Health Insurance Coverage

Immigrant Child (%)

Child U.S.-Born, Immigrant Parents (%)

Child and Parents U.S. Born (%)

No Usual Source of Care

28

(25,32)

8

(6,9)

5

(5,6)

Did Not Have a Physician Visit During Past Year

 

All ages (0-17)

32

(28,36)

18

(16,19)

18

(17,19)

Ages 0-2

8

(0,19)

6

(4,8)

5

(4,6)

Ages 3-5

16

(7,24)

10

(8,13)

10

(9,12)

Ages 6-17

35

(31,40)

26

(123,28)

23

(23,24)

Immigrant children are less likely to have a usual source of care than nonimmigrant children regardless of their health insurance status—whether uninsured, on Medicaid, or with private/ other coverage (data not shown). However, uninsured immigrant children are less likely to have a connection to the health care system (51 percent lack a usual source of care) than those with Medicaid or private/other coverage. Uninsurance increases the risk of not having a usual person/place for medical care for U.S.-born children of immigrant parents and for nonimmigrant as well as immigrant children.

The two main reasons identified for being without a usual source of care were the same for each ethnic group: lack of per-

Suggested Citation:"3 Access to Health Insurace and Health Care for Children in Immigrant Families." National Research Council. 1999. Children of Immigrants: Health, Adjustment, and Public Assistance. Washington, DC: The National Academies Press. doi: 10.17226/9592.
×

 

Latino

Asian

Main Reason for Lack of Health Insurance Coverage

Immigrant Child (%)

Child U.S.-Born, Immigrant Parents (%)

Child and Parents U.S. Born (%)

Immigrant Child (%)

Child U.S.-Born, Immigrant Parents (%)

Child and Parents U.S. Born (%)

No Usual Source of Care

36

(30,42)

12

(10,14)

7

(6,9)

26

(19,33)

6

(3,8)

a

Did Not Have a Physician Visit During Past Year

 

All ages (0-17)

39

(33,45)

20

(17,23)

17

(15,20)

34

(26,43)

20

(16,24)

17

(8,26)

Ages 0-2

a

7

(4,11)

3

(1,6)

a

5

(0,11)

a

Ages 3-5

19

(4,34)

11

(6,15)

9

(5,13)

8

(0,43)

13

(6,21)

a

Ages 6-17

42

(35,49)

30

(26,34)

25

(22,29)

39

(130,48)

28

(22,34)

25

(12,38)

ceived need for or trust in doctors and lack of affordable care, including being uninsured. Relocation or lack of availability of a previous doctor and difficulty finding care also were identified but by a smaller proportion of respondents (see Table 3-9). The relative importance of these factors did vary, however, by immigrant group. Cost barriers were more important for children not born in the United States and U.S.-born children of immigrants than for nonimmigrant children. In contrast, the relocation of a previous physician was more important for nonimmigrant children.

Among children with a usual source of care, the physician

Suggested Citation:"3 Access to Health Insurace and Health Care for Children in Immigrant Families." National Research Council. 1999. Children of Immigrants: Health, Adjustment, and Public Assistance. Washington, DC: The National Academies Press. doi: 10.17226/9592.
×

 

Black

Main Reason for Lack of Health Insurance Coverage

Immigrant Child (%)

Child U.S.-Born, Immigrant Parents (%)

Child and Parents U.S. Born (%)

No Usual Source of Care

19

(8,31)

5

(2,9)

7

(6,8)

Did Not Have a Physician Visit During Past Year

 

All ages (0-17)

19

(8,30)

14

(8,19)

23

(21,24)

Ages 0-2

a

9

(0,18)

8

(5,11)

Ages 3-5

a

10

(0,20)

12

(9,15)

Ages 6-17

21

(9,33)

18

(10,27)

29

(27,32)

a Sample size too small to make a reliable estimate.

SOURCE: 1994 National Health Interview Survey.

office or private clinic is the most frequently reported site of care across immigrant groups (see Table 3-10). It is, however, more common for nonimmigrant children to use private offices than it is for immigrant children and U.S.-born children with immigrant parents. For children, having access to a health care provider is critical for reasons beyond acute care needs. Children need a regular connection for well-baby/child checkups, preventive care, and developmental assessments.

Suggested Citation:"3 Access to Health Insurace and Health Care for Children in Immigrant Families." National Research Council. 1999. Children of Immigrants: Health, Adjustment, and Public Assistance. Washington, DC: The National Academies Press. doi: 10.17226/9592.
×

 

White

Main Reason for Lack of Health Insurance Coverage

Immigrant Child (%)

Child U.S.-Born, Immigrant Parents (%)

Child and Parents U.S. Born (%)

No Usual Source of Care

23

(17, 29)

5

(3, 6)

5

(4, 5)

Did Not Have a Physician Visit During Past Year

 

All ages (0-17)

27

(21,33)

16

(13,18)

17

(16,18)

Ages 0-2

7

(0,25)

4

(1,8)

4

(3,5)

Ages 3-5

19

(4,34)

9

(5,13)

10

(9,12)

Ages 6-17

29

(22,36)

22

(19,26)

22

(21, 23)

Use of Health Care Services

Immigrant children are less likely than either children of immigrants or children with U.S.-born parents to have had a doctor visit during the past year (see Table 3-8). One-third (32 percent) of immigrant children did not have a doctor visit during the past 12 months. These lower rates for immigrant children are seen for Latinos, Asians, and whites but not for blacks. Comparisons by age show that children 6 to 17 years old across all immigrant groups are less likely than younger children to have had a physi-

Suggested Citation:"3 Access to Health Insurace and Health Care for Children in Immigrant Families." National Research Council. 1999. Children of Immigrants: Health, Adjustment, and Public Assistance. Washington, DC: The National Academies Press. doi: 10.17226/9592.
×

TABLE 3-9 Reasons for No Usual Source of Care by Immigration Status Among Children with No Usual Source of Care, Ages 0 to 17, United States, 1994

 

Immigrant Child (%)

Child of Immigrant Parents (%)

Nonimmigrant Child (%)

Don't need or like doctors

45

39

40

Can't afford, no insurance

40

40

24

Previous doctor not available/moved

4

8

17

Hard to find care

2

2

6

Speaks different language

< 1

< 1

< 1

Other

9

10

12

 

SOURCE: 1994 National Health Interview Survey.

TABLE 3-10 Type of Usual Source of Care by Immigration Status Among Children with a Usual Source of Care, Ages 0 to 17, United States, 1994

 

Immigrant Child

Child of Immigrant Parents

Nonimmigrant Child

Doctor's office/private clinic

63

68

84

County/public clinic

9

7

4

Community/migrant clinic

6

3

3

Health maintenance organization/prepaid group

10

8

5

Emergency room

< 1

< 1

< 1

Other

11

13

5

 

SOURCE: 1994 National Health Interview Survey.

Suggested Citation:"3 Access to Health Insurace and Health Care for Children in Immigrant Families." National Research Council. 1999. Children of Immigrants: Health, Adjustment, and Public Assistance. Washington, DC: The National Academies Press. doi: 10.17226/9592.
×

cian visit during the past year. These lower rates are more pronounced for immigrant children. The large proportion of children, especially immigrant children, who lack adequate contact with the health care system is a cause for concern, given the age-specific needs for well-child checkups and immunizations.

Uninsured children are less likely to have had a doctor visit during the past year than children with coverage. Among immigrant children, 43 percent of those without coverage did not have a recent doctor visit, compared to 28 percent of those with private/other coverage and 16 percent of their counterparts with Medicaid (data not shown in table). The comparative advantage of children with private/other coverage over uninsured children demonstrates the financial access that insurance coverage provides. The relative disadvantage of children with private/other coverage compared to Medicaid may be due to the financial barriers imposed on low-income populations by deductibles and copayments—prevalent with private insurance and absent or minimal with Medicaid. U.S.-born children of immigrants and nonimmigrant children also are disadvantaged by lack of coverage; those without coverage are twice as likely as those with Medicaid or private/other coverage to have not had a doctor visit during the past year.

Immigration, Ethnicity, Usual Source of Care, and Doctor Visits

To understand the factors that influence access to physician use, we conducted multivariate regression analyses. The models were tested for interactions among key analysis variables by examining the independent effects of these variables on children receiving at least one physician visit. When an interaction was suspected, based on observed changes in the direction of the coefficient, the presence of an interaction was tested. The models for physician visits account for the interactions found between poverty and immigration status and education and immigration status. We illustrate the effects of insurance status and having a usual source of care on receipt of physician visits by children with the following characteristics, held constant across different ethnic groups: U.S.-born child with at least one immigrant parent; child

Suggested Citation:"3 Access to Health Insurace and Health Care for Children in Immigrant Families." National Research Council. 1999. Children of Immigrants: Health, Adjustment, and Public Assistance. Washington, DC: The National Academies Press. doi: 10.17226/9592.
×

is female, 3 to 5 years old, in good to excellent health, with no activity limitations; living in a family of four with family income between 100 and 199 percent of poverty; and whose mother did not graduate from high school.

The presence or absence of health insurance and a usual source of care have a consistent and strong effect on the probability of having a doctor visit. Across all ethnic groups, children with the defined characteristics who have Medicaid coverage and a usual source of care have a higher probability of receiving a doctor visit compared with similar children who have Medicaid coverage but no usual source of care, those who are uninsured but have a usual source of care, and particularly those who are both uninsured and have no usual source of care (see Table 3-11 and Figure 3-4).

The difference between the conditions with the highest and lowest probabilities of physician visits within each ethnic group are dramatic. Among U.S.-born Asian children in immigrant families—the ethnic group that is most disadvantaged in access

TABLE 3-11 Predicted Probabilities of at Least One Physician Visit During Past Year Among U.S.-Born Children with Immigrant Parents by Ethnicity, Ages 3 to 5, United States, 1994a

 

Uninsured

Medicaid

 

No Usual Source of Care (%)

Has Usual Source of Care (%)

No Usual Source of Care (%)

Has Usual Source of Care (%)

Latino

63

83

81

92

Asian

51

76

72

88

Black

75

90

88

96

White

78

91

89

96

a U.S.-born child with at least one immigrant parent; child is female, 3 to 5 years old, in good to excellent health with no activity limitations, living in a family of four with family income of 100 to 199 percent of poverty level, and whose mother did not graduate from high school.

SOURCE: 1994 National Health Interview Survey.

Suggested Citation:"3 Access to Health Insurace and Health Care for Children in Immigrant Families." National Research Council. 1999. Children of Immigrants: Health, Adjustment, and Public Assistance. Washington, DC: The National Academies Press. doi: 10.17226/9592.
×

FIGURE 3-4 Predicted probabilities of having at least one physician visit during the past year among U.S.-born children with immigrant parents by ethnicity and other selected characteristics, ages 3 to 5, 1994. Predicted probabilities are for a female child, 3 to 5 years old, in good to excellent health, living in a two-parent family with at least one parent employed full time for the full year, a family income of 100 to 199 percent of the federal poverty level, and one parent who has not graduated from high school. Source: March 1994 National Health Interview Survey.

Suggested Citation:"3 Access to Health Insurace and Health Care for Children in Immigrant Families." National Research Council. 1999. Children of Immigrants: Health, Adjustment, and Public Assistance. Washington, DC: The National Academies Press. doi: 10.17226/9592.
×

to doctor visits—those who are both uninsured and have no usual source of care have a 51 percent probability of receiving at least one physician visit in a year, compared with an 88 percent probability for similar children who have Medicaid coverage and a usual source of care. Uninsured U.S.-born Latino children in immigrant families who have no usual source of care have a 63 percent probability of at least one physician visit annually, compared with 92 percent for those who have Medicaid and a usual source of care. Black and white U.S.-born children in immigrant families demonstrate similar benefits of having both Medicaid and a regular source of care. The strong effect of usual source of care on the probability of having a doctor visit is unaffected by the type of source a child has—whether a private physician's office, a school or community clinic, a county hospital or clinic, or even a hospital emergency room (data not shown in table).

These predicted probabilities underscore the importance of having both health insurance coverage and a regular connection to the health care system. Children who have a usual source of care have even higher probabilities of receiving at least one physician visit, even if they are uninsured. Uninsured children with a usual source of care have rates similar to Medicaid children without a usual source. The combination of both Medicaid coverage and having a regular source of care provides the best opportunities for children to meet the recommended minimum number of contacts with the health care system.

We also examined access to health care for U.S.-born children in immigrant families in the six states with the largest immigrant populations (California, Texas, New York, Florida, Illinois, and New Jersey. To illustrate this relationship at the state level and to demonstrate the differences across states, we developed predicted probabilities of at least one physician visit for a U.S.-born child with at least one immigrant parent with the specified characteristics: Latino, female, 3 to 5 years old, good to excellent health and no activity limitations, family of four, family income between 100 and 199 percent of poverty, and mother who did not graduate from high school.

Within each of these six states, children were less likely to have received at least one physician visit if they were uninsured and lacked a usual source of care (see Figure 3-5). Moreover, dif-

Suggested Citation:"3 Access to Health Insurace and Health Care for Children in Immigrant Families." National Research Council. 1999. Children of Immigrants: Health, Adjustment, and Public Assistance. Washington, DC: The National Academies Press. doi: 10.17226/9592.
×

FIGURE 3-5 Predicted probabilities of having at least one physician visit during the past year among U.S.-born Latino children with immigrant parents by state of residence and other selected characteristics, ages 3 to 5, selected states, 1994. Predicted probabilities are for a female child, 3 to 5 years old, in good to excellent health, living in a two-parent family with at least one parent employed full time for the full year, a family income of 100 to 199 percent of the federal poverty level, and mother who has not graduated from high school. Source: 1994 National Health Interview Survey.

Suggested Citation:"3 Access to Health Insurace and Health Care for Children in Immigrant Families." National Research Council. 1999. Children of Immigrants: Health, Adjustment, and Public Assistance. Washington, DC: The National Academies Press. doi: 10.17226/9592.
×

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

Suggested Citation:"3 Access to Health Insurace and Health Care for Children in Immigrant Families." National Research Council. 1999. Children of Immigrants: Health, Adjustment, and Public Assistance. Washington, DC: The National Academies Press. doi: 10.17226/9592.
×

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

Suggested Citation:"3 Access to Health Insurace and Health Care for Children in Immigrant Families." National Research Council. 1999. Children of Immigrants: Health, Adjustment, and Public Assistance. Washington, DC: The National Academies Press. doi: 10.17226/9592.
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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

Suggested Citation:"3 Access to Health Insurace and Health Care for Children in Immigrant Families." National Research Council. 1999. Children of Immigrants: Health, Adjustment, and Public Assistance. Washington, DC: The National Academies Press. doi: 10.17226/9592.
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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

Suggested Citation:"3 Access to Health Insurace and Health Care for Children in Immigrant Families." National Research Council. 1999. Children of Immigrants: Health, Adjustment, and Public Assistance. Washington, DC: The National Academies Press. doi: 10.17226/9592.
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effect on the health of immigrant children and even U.S. citizen children in immigrant families.

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Suggested Citation:"3 Access to Health Insurace and Health Care for Children in Immigrant Families." National Research Council. 1999. Children of Immigrants: Health, Adjustment, and Public Assistance. Washington, DC: The National Academies Press. doi: 10.17226/9592.
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Suggested Citation:"3 Access to Health Insurace and Health Care for Children in Immigrant Families." National Research Council. 1999. Children of Immigrants: Health, Adjustment, and Public Assistance. Washington, DC: The National Academies Press. doi: 10.17226/9592.
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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

Suggested Citation:"3 Access to Health Insurace and Health Care for Children in Immigrant Families." National Research Council. 1999. Children of Immigrants: Health, Adjustment, and Public Assistance. Washington, DC: The National Academies Press. doi: 10.17226/9592.
×

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.

Suggested Citation:"3 Access to Health Insurace and Health Care for Children in Immigrant Families." National Research Council. 1999. Children of Immigrants: Health, Adjustment, and Public Assistance. Washington, DC: The National Academies Press. doi: 10.17226/9592.
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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

Suggested Citation:"3 Access to Health Insurace and Health Care for Children in Immigrant Families." National Research Council. 1999. Children of Immigrants: Health, Adjustment, and Public Assistance. Washington, DC: The National Academies Press. doi: 10.17226/9592.
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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-

Suggested Citation:"3 Access to Health Insurace and Health Care for Children in Immigrant Families." National Research Council. 1999. Children of Immigrants: Health, Adjustment, and Public Assistance. Washington, DC: The National Academies Press. doi: 10.17226/9592.
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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.

Suggested Citation:"3 Access to Health Insurace and Health Care for Children in Immigrant Families." National Research Council. 1999. Children of Immigrants: Health, Adjustment, and Public Assistance. Washington, DC: The National Academies Press. doi: 10.17226/9592.
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Suggested Citation:"3 Access to Health Insurace and Health Care for Children in Immigrant Families." National Research Council. 1999. Children of Immigrants: Health, Adjustment, and Public Assistance. Washington, DC: The National Academies Press. doi: 10.17226/9592.
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Suggested Citation:"3 Access to Health Insurace and Health Care for Children in Immigrant Families." National Research Council. 1999. Children of Immigrants: Health, Adjustment, and Public Assistance. Washington, DC: The National Academies Press. doi: 10.17226/9592.
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Suggested Citation:"3 Access to Health Insurace and Health Care for Children in Immigrant Families." National Research Council. 1999. Children of Immigrants: Health, Adjustment, and Public Assistance. Washington, DC: The National Academies Press. doi: 10.17226/9592.
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Suggested Citation:"3 Access to Health Insurace and Health Care for Children in Immigrant Families." National Research Council. 1999. Children of Immigrants: Health, Adjustment, and Public Assistance. Washington, DC: The National Academies Press. doi: 10.17226/9592.
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Suggested Citation:"3 Access to Health Insurace and Health Care for Children in Immigrant Families." National Research Council. 1999. Children of Immigrants: Health, Adjustment, and Public Assistance. Washington, DC: The National Academies Press. doi: 10.17226/9592.
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Children of Immigrants: Health, Adjustment, and Public Assistance Get This Book
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Immigrant children and youth are the fastest-growing segment of the U.S. population, and so their prospects bear heavily on the well-being of the country. Children of Immigrants represents some of the very best and most extensive research efforts to date on the circumstances, health, and development of children in immigrant families and the delivery of health and social services to these children and their families.

This book presents new, detailed analyses of more than a dozen existing datasets that constitute a large share of the national system for monitoring the health and well-being of the U.S. population. Prior to these new analyses, few of these datasets had been used to assess the circumstances of children in immigrant families. The analyses enormously expand the available knowledge about the physical and mental health status and risk behaviors, educational experiences and outcomes, and socioeconomic and demographic circumstances of first- and second-generation immigrant children, compared with children with U.S.-born parents.

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