Journal Issue: Immigrant Children Volume 21 Number 1 Spring 2011
Improving Access to Health Insurance and Health Care
Access to health care substantially influences the physical and emotional health status of children of immigrants. Less likely to have health insurance and regular access to health care services, immigrant parents delay or forgo needed care for their children. When children finally receive care, it is often in the emergency room after an urgent or life-threatening condition has developed.
In 2008, nearly 45 percent of noncitizen U.S. residents, 18 percent of naturalized citizens, and 13 percent of U.S.-born citizens lacked health insurance coverage.68 Because most children depend on their parents to obtain health insurance, parental citizenship and immigration status can influence children's health insurance status (figure 3). Foreign-born parents and their children are more likely to be uninsured because parents are frequently self-employed or working for employers who do not offer health insurance, have lower incomes limiting their capacity to purchase insurance in the private market, and face restrictions on eligibility for public insurance programs.69 When offered insurance coverage by their employers, roughly 85 percent of employees take up this coverage, and there are no differences in take-up rates between citizens and noncitizens.
Immigrants' eligibility for public health insurance is dependent on federal and state policies. Coverage rates among legal immigrants have declined over the past decade as a result of 1996 welfare reforms that prohibited foreign-born children from receiving federally funded Medicaid and state Children's Health Insurance Program (CHIP) coverage until they had been in the country for at least five years. To fill this coverage gap, some states provided public insurance coverage using state-only funds. In the interest of promoting the health of newborns, several of these states also provided prenatal coverage to immigrant women regardless of their immigration status. In early 2009 the federal Children's Health Insurance Program Reauthorization Act updated the funding rules for CHIP and provided federal matching funds to states that covered eligible legal first-generation immigrant children and pregnant women regardless of their date of entry into the United States. However, states are not required to provide access to CHIP and can choose not to take advantage of the new option. As of February 2010, thirty states and the District of Columbia had chosen to provide public health insurance coverage to at least some qualified legal immigrants (figure 4).70 In these thirty states, nearly one of every five children is a child of an immigrant.
Still, many children of immigrants (56 percent of children with two immigrant parents and 66 percent of children with one foreign-born and one U.S-born parent) eligible for public health insurance do not enroll.71 Approximately 81 percent of children (up to age eighteen) in immigrant families were born in the United States and are U.S. citizens. But an estimated 30 percent of children of immigrants are unauthorized or living with a parent who may not be living in the United States legally.72 Thus, parents of U.S. citizen children may forgo public health insurance and other services because of their own legal status and mistaken fears that they will be deemed a "public charge" if their children receive public health insurance benefits.73 Immigrants deemed a public charge can be denied U.S. citizenship or prohibited from sponsoring the immigration of a family member. In addition to concerns regarding their legal status, immigrant parents face financial and language barriers that can limit their capacity to enroll in both private and public health insurance programs.
Health Care Use
Without health insurance and even with insurance, families sometimes forgo critical preventive, diagnostic, and treatment services for their children. Among noncitizen children up to age seventeen, 37 percent lacked a usual source of care and 30 percent had not seen a medical doctor in the past year. Only 5 percent of citizen children lacked a usual source of care; only 9 percent had forgone an annual doctor's visit. Because they use less care, annual medical expenditures per capita were substantially lower for noncitizen children and their parents ($1,797) than for citizens ($3,702) in 2005.74
Both financial and nonfinancial barriers compromise the ability of immigrant parents to obtain access to medical care.75 Financial impediments include not only out-of-pocket costs for services and prescriptions but also the lack of paid sick leave or the ability to leave work to take their children to appointments during standard office hours. Language is one particularly important nonfinancial barrier for the children of immigrants and their parents. Immigrants with limited English proficiency report lower satisfaction with care, less knowledge of their medical condition, and difficulty understanding instructions on medication usage. Additionally, low levels of health literacy limit immigrant parents' abilities to use health services effectively or to act as advocates for their children in health care settings.
When immigrants face challenges obtaining physician-based medical care, they may turn to complementary and alternative medical providers such as acupuncturists or spiritual healers. Data from the California Health Interview Survey show that more than 22 percent of Latino and 23 percent of Asian adults reported using alternative medicine providers, and almost 20 percent of Latinos and 50 percent of Asians reported using traditional or herbal remedies.76
In addition, uninsured immigrants turn to health care providers working in federally qualified community health centers (FQHCs)—public and private nonprofit organizations serving populations with limited access to care.77 In 2008 FQHCs provided care to 17 million patients. Of these, 25 percent primarily spoke a language other than English, 36 percent were children, and 38 percent were uninsured.78 Uninsured immigrants, however, are less likely to use emergency rooms. Only 13 percent of adult and 12 percent of child noncitizens report an emergency room visit in the past year compared with 20 percent of adult and 22 percent of child citizens.79 Despite this lower frequency of use, emergency room expenditures are three times higher per capita for foreign-born children than for U.S.-born children.80 Thus, at least for children, delaying medical care can have substantial costs. Moreover, because immigrant parents cannot build long-term relationships with providers in these settings, their children may receive lower-quality care.