Non-citizen children from families with mixed immigration status in the United States were much more likely to be uninsured than their citizen siblings, and this lack of coverage resulted in delays in needed medical care, according to a recent study.
Examination of family data from 2008 to 2018 where at least one child had citizenship and another did not show that 42% of non-citizen children were uninsured compared to 12% of those who had citizenship, a reported Leighton Ku, MD, PhD, of the George Washington University School of Public Health in Washington, DC, and Mariellen Jewers, PhD, of the Open Avenues Foundation in Boston.
Unsurprisingly, due to legal restrictions, significantly fewer non-citizen children were publicly insured through the Children’s Health Insurance Program (CHIP) or Medicaid (39% of non-citizens vs. 73% of brothers and sisters). citizen sisters). Private insurance, for which citizenship status is irrelevant, was similar (19% vs. 15%, respectively), according to the results in the July issue of Health affairs.
Non-citizen status “leads to inferior insurance coverage and reduced access to care,” Ku said at a briefing on Tuesday hosted by Health affairs, adding that more than twice as many non-national children suffered delays in treatment for necessary medical care (7% vs. 3%).
“This was mainly due to insurance services,” and the associated care costs, Ku said during the briefing, sponsored by the California Health Care Foundation, California Endowment and Con Alma Health Foundation. He noted that after checking the insurance status, the difference in processing times disappeared.
A second analysis of the study found that more than two-thirds of these non-citizen children eventually became citizens at the age of 30 or older.
Legal restrictions and exclusions from CHIP eligibility have been in place for decades – with a range of such restrictions related to immigration status operating in 48 states, as of 2020. A 1996 federal law established a period of ‘5-year wait for legal non-citizens to be eligible for Medicaid or CHIP. Another federal law in 2009 gave states the ability to waive the waiting period and provide coverage for legal immigrant children and pregnant women, but undocumented children continued to be excluded.
In their article, Ku and Jewers explained that “eligibility restrictions that prevent non-national children from being publicly insured can contribute to their poor health and higher medical costs in their adult lives.”
Their study drew on data from two sources: the National Health Interview Survey (NHIS) from the National Center for Health Statistics, from 2008 to 2018, and the Current Population Survey (CPS) 2020 from the Census Bureau. NHIS data allowed researchers to assemble a sample of mixed-status families, while census data was used in a separate analysis to determine the extent to which non-citizen children ultimately became citizens.
Overall, the study included 251,861 child citizens and 8,282 non-citizen children in the United States, as well as 8,405 children from 2,832 “single mixed-status families.”
Using the ‘family-level fixed-effects model’, the researchers were able to control for variables such as the race, ethnicity and country of origin of parents, as well as the employment and education of parents. parents, family income, and Medicaid policies of different states related to family residence or year of survey. The model also controlled for more difficult-to-observe variables such as parents’ feelings about insurance and health care use, the study noted. The analysis also controlled for age and sex, with non-citizen children tending to be older than citizen children.
“The net effect of having this fixed-effect system, where we can control all the characteristics within families, [is] this provides very strong evidence of causation, ”said Ku.
While these models are “not as definitive as the randomized experiments,” the study noted, the fixed-effect models provide “a solid basis for identifying Medicaid and CHIP eligibility restrictions against non-nationals as caused by the poor health insurance status of immigrant children and limited access to medical care. “
The researchers focused on three main results:
- Insurance coverage at the time of the survey
- Whether or not parents postponed medical care due to costs in the past year
- Child’s health (on a Likert scale of 1 to 5, ranging from poor to excellent)
The researchers found no significant difference in health status. “It’s just because most of the children are in excellent health,” said Ku. “So we don’t see a lot of these differences.”
In the second analysis using CPS 2020 data from the Census Bureau, researchers retrospectively examined adults who came to the United States as non-citizen children and found that 70% of those people became citizens by the age of 30 years or older.
Ku said the common thread between the two analyzes is the issue of fairness.
“And the question is, ‘Why would we want to build barriers that make children from the same families be treated differently?'” He said. “I don’t see why, as a politician, the United States would want to do this.”
When possible, as parents’ experience with private insurance clearly shows, parents “tend to cover their children the same way” regardless of their citizenship status, Ku said.
Ku argued that current US policy threatens children’s health insurance status and compromises their access to health care.
Although the study did not find any differences in health status between citizen and non-citizen siblings, other studies have shown the beneficial effects of children receiving Medicaid early in life, a- he noted.
“Our analyzes of CPS data indicate that the majority of non-citizen children grow up to be US citizens,” Ku and Jewers wrote in their article. “Excluding them from health insurance coverage hampers their access to health care and can ultimately harm their health, both in childhood and into adulthood.”
For this reason, Ku argued that lawmakers should consider removing restrictions on Medicaid related to citizenship. He pointed out that under current law all states have the option to remove the 5-year waiting period and about half have done so. Many states could go even further, such as California has done, he noted.
“We harm future citizens if we refuse coverage early in life,” Ku said.