From Generation to Generation The Health and Well-Being of Children in Immigrant Families (1998) / Chapter Skim
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4 Public Policies
4 Public Policies
Pages 111-154
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From page 111... ...
It examines patterns of health insurance coverage, access to and use of health services, and barriers to access. It is beyond the scope of this report to do more than touch on the highlights of U.S.
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From page 112... ...
And, as of this writing, efforts to restore benefits to immigrants are ongoing at the federal level. The law's impact on immigrant children derives in large part from the programmatic reach of new restrictions on immigrants' eligibility for public benefits, which encompass the benefit programs of Medicaid, Supplemental Security Income (SSI)
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From page 113... ...
Prior to welfare reform, legal immigrants were eligible for public benefits on essentially the same terms as U.S.-born citizens (Fix and Zimmerman, 1995~.3 Currently, most immigrants (except for refugees) who are in the United States legally are barred from eligibility for food stamps, 3Naturalized citizens enjoyed the same entitlements as other citizens.
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From page 114... ...
114 o tr o o .
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From page 115... ...
in this reformulation of eligibility remains unclear, although it appears that it will be considered a federal means-tested program and so will follow the rules that apply to Medicaid. This program, enacted as part of the Balanced Budget Act of 1997, provides funds to states to enable them to initiate and expand the provision of child health insurance to uninsured, low-income children under age 19.
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From page 116... ...
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From page 117... ...
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From page 118... ...
has limited current legal immigrants' access to TANF, Medicaid, or Title XX block grant programs. States are, however, showing wide variation in their decisions about whether to replace lost federal funds with state-funded programs for immigrants arriving after the enactment of welfare reform.
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From page 119... ...
Fifth, the requirement for verification of immigration status has been expanded to apply to all "federal public benefits," the definition of which remains to be determined but could be quite broad. Likely to be included, for example, is Head Start, maternal and child health programs, the Child Care and Development Block Grant, and other programs that have benefited immigrant children.
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From page 120... ...
This represents a marked shift in the nation's policies for immigrant children. Access Prior to Welfare Reform Throughout America's history, immigrants have had a profound effect on the composition of the country's population and have presented daunting social and economic challenges to successive American generations.
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From page 121... ...
In contrast to these relatively unrestricted, comprehensive, and explicit immigration policies, the United States has had no explicit immigrant policy guiding the settlement and orientation of immigrants, or determining the nature and amount of public benefits available to immigrants after arrival (Fix and Passel, 1994; Simon, 1989~; the exception is resettlement policies focused on refugees. Instead, immigrants have experienced varied eligibility criteria in the context of specific legislation regarding public benefits.
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From page 122... ...
Increasingly, however, the school nurse became crucial not only in detecting disease but also in health education, including educating parents about health care for their children. School nurses treated minor ailments, thus preventing loss of instruction time, and provided health care outreach to parents.
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From page 123... ...
, Eastern European Jews created and joined the Landsmannschain (regionally based fraternal organizations) , and Cuban cigar makers contributed part of their wages to the formation of clinical, providing access to health insurance or services (Davis, 1921; Kalet, 1916; Kraut, 1995; Mormino and Pozzetta, 1987~.
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From page 124... ...
. Programs focused on children, such as WIC, childhood immunization programs, emergency medical services, Head Start, the school lunch and breakfast programs, and Title IV foster care and adoption assistance, have also been of great importance to immigrant children,
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From page 125... ...
The first is the federal government's preemption of state power to determine noncitizens' eligibility for state or federally funded public benefits programs. Prior to 1972, federal statutes controlling state or local public benefit programs contained no eligibility restrictions based on immigration status; they were silent on the matter of immigrant eligibility.
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From page 126... ...
5Even prior to passage of the welfare reform legislation, public benefits for immigrants have been restricted. For example, immigrants whose status was legal
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From page 127... ...
(Hofferth, 1998) to provide information about children in families that received public assistance.6 The discussion in this section relies on these analy ized under the Immigration Reform and Control Act were barred from receiving public assistance for five years, and some share of legal immigrants have been barred from means-tested benefits as a result of requirements that their sponsors' income be included in determining eligibility for their first three years in the country (Fix and Passel, 1994~.
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From page 128... ...
On one hand, first-generation children experience relatively high poverty rates and therefore might be expected to show higher rates of receipt than later-generation children. On the other hand, all persons born in the United States are eligible to apply for public benefits, and legal immigrants are eligible to apply for more benefit programs than are undocumented immigrants.
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From page 130... ...
Compared with white children, higher probabilities of receipt of public assistance from specific programs were usually found for Mexican, Cuban, other Hispanic, and Asian children. In the PSID analyses, which encompassed Mexican-origin, Cuban-origin, and other Hispanic children, the range of those living in families that received at least one form of public assistance among those listed was from 29 to 61 percent.
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From page 131... ...
Third- and later-generation Mexican children, however, are generally more likely than third-and later-generation white children with the same socioeconomic and demographic characteristics to receive benefits. The situation is quite different for Asian children in immigrant families.
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From page 133... ...
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From page 134... ...
Many Cuban-origin children in immigrant families are also entitled to refugee benefits and, not surprisingly, their patterns of reliance on public assistance are similar to those of Asian children. Among those with similar demographic and socioeconomic circumstances, first- and second-generation Cuban-origin children are more likely than either third- and later-generation Cuban children or third- and later-generation white children to live in families that receive SSI and food stamps.
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From page 135... ...
Such an assessment will need to consider: (1) the direct effects on children of their elimination from eligibility for basic benefit programs, ranging from health care and nutrition to social services; (2)
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From page 136... ...
The committee had analyses conducted of existing national data Betsy to provide descriptive data on health insurance coverage and access to health services by children in immigrant families prior to implementation of both welfare reform and the new State Children's Health Insurance Program (Brown et al., 1998~. Much of the discussion in this chapter relies on these analyses and, as such, is most appropriately viewed Analyses of the March 1996 Current Population Survey and the 1994 National Health Interview Survey were conducted by the University of California at Los Angeles Center for Health Policy Research (Brown et al., 1998)
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From page 137... ...
The majority of them receive health coverage through their parents' employer-sponsored health insurance (59 percent of 0- to 17-year-olds in 1995) (Institute of Medicine, 1998, citing Employee Benefit Research Institute, 1997b)
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From page 138... ...
. This association suggests that some children may have been dropped from or lost private health insurance coverage because they became eligible for Medicaid.
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From page 139... ...
Hispanic children are the most likely to lack health insurance. They have the highest uninsured rates for each generation (rang i°Estimates regarding health insurance coverage and access to health care in this section are based on results for first-generation children who are not citizens, first-generation children who are citizens, second-generation children who are citizens, and third- and later-generation children who are citizens.
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From page 140... ...
The finding of high uninsurance rates among Hispanic immigrant children compared with immigrant children from other ethnic groups was replicated in analyses that controlled for family structure, parents' education and employment, and family income that is, among those with similar demographic and socioeconomic circumstances, first-generation Hispanics are more likely to lack health insurance coverage than other first-generation children. Among second-generation children, however, Hispanics, Asians, and whites had quite comparable rates of
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From page 141... ...
Hispanic children whether first- or secondgeneration are less likely to receive employment-based coverage than corresponding generations of white, black, and Asian children. It is especially striking that, by the second generation, about two-thirds of Asian, black, and white children and adolescents have employment-based health insurance, compared with only 35 percent of second-generation Hispanic children.
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From page 142... ...
Mother" includes privately purchased health insurance, Medicare, and other public programs.
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From page 143... ...
Children in more advantaged families from other sending countries such as Hong Kong, Japan, Singapore, and Taiwan; Europe; China; and the Philippines, Malaysia, and Indonesia all rank higher in their rates of insurance coverage than those from Latin American countries. These children have higher rates of employment-based health insurance, which workers with higher levels of educational attainment typically can obtain.
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From page 144... ...
USE OF HEALTH CARE Given that health insurance facilitates the access of children to care, differences in coverage should be reflected in differential patterns of access to and use of health care. But access to health care services depends on more than health insurance coverage; it also requires that families develop a connection to the health care system for their children a regular practitioner or place that can provide continuity of care over time and even across family members and serve as a guide to appropriate preventive care and needed specialized services.
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From page 145... ...
Both health insurance coverage and having a usual source of
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From page 146... ...
146 FROM GENERATION TO GENERATION TABLE 4-6 Children Who Did Not See a Doctor in the Past Year (Percentage) , 1994 All ages Ages O Ages 3 Ages 6 (0-17)
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From page 147... ...
Children in immigrant families who are uninsured and who have no usual source of care have the lowest probability of having seen a doctor. Those who are uninsured but have a usual source of care, as well as those who have private health insurance or Medicaid coverage but no usual source of care, both have a substantially greater probability of seeing a doctor.
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From page 148... ...
Specifically, Asian children were substantially less likely than other children to have seen a doctor in the past 12 months when they lacked both health insurance and a usual source of care. In sum, children in immigrant families show patterns of primary health care use, as measured by having had a doctor's visit in the past year, that correspond closely to their patterns of insurance coverage and reports of having a usual source of care.
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From page 149... ...
Medicaid and Reduced Access to Care Limited availability of neighborhood-based primary health care facilities is frequently cited as a barrier to appropriate and timely health care by low-income families. Physicians are not required to participate in Medicaid, and 25 percent of U.S.
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From page 150... ...
The Shift to Managed Care In principle, some features of managed care, such as coordination of care by case managers and assignment of care providers to specific patients on a long-term basis, have the potential to improve access to care in the low-income eligible population. Evidence to date is mixed, however, and there are virtually no data on how immigrant children are faring in managed care settings.
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From page 151... ...
Furthermore, the dearth of bilingual health care practitioners and multilingual health messages may undermine the ability of immigrant children and their families to receive health information, communicate with health providers, and identify health services in their community (Andersen et al., 1981; Giachello, 1994; Moll et al., 1976; Solis et al., 1990; Wood et al., 1995~. There is a strong consensus among health care professionals that the delivery of high-quality health care and mental health services to immigrant children and their families must be done in ways that are culturally competent and culturally sensitive and must take into account language barriers (American Academy of Pediatrics, 1997b)
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From page 152... ...
Among Mexican-origin children, who account for about one-third of all children in immigrant families, the first, second, and third and later generations are all more likely than third- and later-generation white children to live in families receiving public benefits. It is disadvantaged socioeconomic and demographic circumstances that account for high levels of public assistance receipt among first-generation children as a whole, and among Mexicanorigin children in immigrant families.
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From page 153... ...
With regard to health care coverage and access, the committee's analyses, which pertain to the situation prior to welfare reform, indicate that substantial disparities in uninsurance ratesnot fully explained by family work status or income characterize children in immigrant families. First-generation children are about three times more likely, and second-generation children are about twice as likely to lack health insurance than are third- and later-generation children.
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From page 154... ...
Medicaid coverage, in particular, appears to increase the number of children in immigrant families who make doctor's visits during the year, without simultaneously increasing hospitalization rates or doctor's visits beyond an annual check-up. Recent reductions in health care coverage affecting potentially 1 in 4 first-generation children if current rates of Medicaid coverage for these children hold are likely to result in poorer access to health care, fewer usual providers or sources of care, and fewer regular doctor's visits than is already the case for this population of children, who prior to welfare reform were already disproportionately likely to lack insurance and consistent health care.
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