Health Insurance Coverage of Children in Mixed-Status

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Health Insurance Coverage of Children in Mixed-Status

Transcript Of Health Insurance Coverage of Children in Mixed-Status

SNAPSH
of America's

Health Insurance Coverage of Children

in Mixed-Status Immigrant Families

by Randy Capps, Genevieve Kenney, and Michael Fix

No. 12

TS3
Families

Public health insurance coverage increased—and rates of

immigrants were already ineligible for most benefits. Immediately

uninsurance decreased—between 1999 and 2002 among two

after enactment of the law, use of public benefits fell, not just

groups of low-income, U.S. citizen children: those with parents

among legal noncitizen children with noncitizen parents, but also

who are native or naturalized U.S. citizens and those with at least

among citizen children in mixed-status families (Zimmermann and

one immigrant parent who is not a U.S. citizen (referred to as

Fix 1998). About the same time, Congress expanded health care

mixed-status families).1 The improvements followed efforts on the

coverage of low-income children by enacting SCHIP, and many

part of the states and the federal government to expand coverage states extended their state-funded health insurance programs to

of children under Medicaid and the State Children’s Health

legal noncitizens (Zimmermann and Tumlin 1999). Between 1999

Insurance Program (SCHIP) and the

and 2002, the federal government

introduction of policies directed at

made it clear that receipt of health

improving Medicaid and SCHIP access for immigrant and non-English-

DATA AT A GLANCE

benefits would not jeopardize the naturalization of immigrant family

speaking families. Nonetheless, more than one in five citizen children in lowincome mixed-status families remained uninsured in 2002—a rate 74 percent

INSURANCE COVERAGE INCREASED 7 PERCENTAGE POINTS FOR CHILDREN IN MIXED-
STATUS FAMILIES BETWEEN 1999 AND 2002.

members or their adjustment to legal permanent resident status (Schlosberg and Wong 2002), and several states with large immigrant

higher than that of children with citizen parents.
This Snapshot uses data from the

IN 2002, 22 PERCENT OF CHILDREN IN MIXEDSTATUS FAMILIES LACKED HEALTH INSURANCE

populations made extensive outreach efforts to these families (Holcomb et al. 2003).

1999 and 2002 National Survey of America’s Families (NSAF) to examine the health insurance coverage2 of low-

COMPARED WITH 12 PERCENT OF CHILDREN WITH CITIZEN PARENTS.

Declines in Uninsurance
The share of all children under age 18

income citizen children.3 (In 2002, 72 percent of all children with noncitizen parents were themselves citizens and thus qualified for benefits on the same

MEDICAID AND SCHIP COVERAGE INCREASED 12 PERCENTAGE POINTS FOR CHILDREN IN MIXED-STATUS FAMILIES.

without health insurance coverage fell from 12.4 percent to 9.4 percent between 1999 and 2002 (data not shown). This gain was driven by a

terms as citizen children with citizen

decline in the uninsurance rate for

parents.) The Snapshot also looks at

low-income children, which fell by 5.9

differences in health insurance coverage between children whose

percentage points. The uninsurance rate for children in higher-

parents or other caregivers responded to the survey in English and

income families did not change significantly during this period

those whose family responded in Spanish. Limited English skills—like (Kenney, Haley, and Tebay 2003).

lack of citizenship—may prevent parents from applying for public

Uninsurance fell for both groups of low-income citizen children

benefits for their children (Holcomb et al. 2003).

between 1999 and 2002: the rate dropped 6.0 percentage points for

children with citizen parents and 7.1 percentage points for children in

Policy Context

mixed-status families (figure 1). Nonetheless, 12.4 percent of children

In 1996, Congress passed welfare reform legislation that restricted with citizen parents and 21.6 percent of children in mixed-status

legal noncitizens’ access to public benefits; undocumented

families were uninsured in 2002. These coverage gaps are consistent

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with gaps reported in a recent study based on Current Population Survey data (Ku and Waidman 2003).
Improvements in coverage among low-income citizen children are attributable to expanded public—not employer—coverage. These children gained Medicaid/SCHIP coverage at high rates between 1999 and 2002: public coverage increased by 13.0 percentage points for children with citizen parents and 11.6 percentage points for children in mixed-status families (figure 2).
Employer-Sponsored Insurance
Much of the coverage gap between the two groups of low-income citizen children stems from the significantly lower rate of employersponsored insurance among children in mixed-status families. Only 22.1 percent of those children had employer coverage in 2002, compared with 34.9 percent of children with citizen parents (figure 2). This disparity reflects the fact that immigrants are less likely than citizens to hold jobs that offer health insurance coverage (Ku and Matani 2001; Schur and Feldman 2001).
Employer-sponsored coverage of low-income citizen children with citizen parents dropped 6.5 percentage points between 1999 and 2002. The already low employer coverage of children in mixedstatus families dropped 4.0 percentage points, a change that was not statistically significant.4
Children in Spanish-Speaking Families
In 1999, citizen children living in low-income families that responded to the NSAF in Spanish had significantly higher health insurance coverage through Medicaid and SCHIP than their counterparts in English-speaking families (44.7 versus 36.3 percent). Children in both groups experienced equivalent gains in public coverage between 1999 and 2002 (figure 3). The higher rate of public coverage of children in Spanish-speaking families is due in part to the substantially lower rate of employer-sponsored insurance of these children.
Gains in public coverage of citizen children in Spanish-speaking families are probably the result of efforts by many health and social service providers across the country to expand their Spanishspeaking staff and improve their capacity to assist Spanish speakers (Holcomb et al. 2003). Outreach for Medicaid and SCHIP was conducted in Spanish during this period, and Executive Order 13166 was issued in 2000, setting language access guidelines for federal agencies and federal aid recipients. In the absence of these outreach and language access efforts, it is unlikely that children in Spanishspeaking families would have shared as greatly in the overall gains in public coverage.

Percent

Figure 1. Uninsurance Rates of Low-Income Citizen Children, by Citizenship of Parents, 1999 and 2002

30

25
19.7 20

15

13.8ˇ

10

■ 1999 ■ 2002
18.5
12.4ˇ

28.7
21.6ˇ

5

0 All low-income citizen children

Those with citizen parents

Those with at least one noncitizen parent

Sources: 1999 and 2002 National Survey of America's Families Notes: Low-income is defined as below 200 percent of the federal poverty thresholds. Percentage point changes are calculated from unrounded estimates for each year and may therefore differ slightly from calculations based on the rounded estimates given here. ˇ Decrease between 1999 and 2002 is significant at the 0.10 level.

Discussion
The findings presented here suggest several conclusions. First, the rising public coverage of citizen children in mixed-status families and in Spanish-speaking families indicates that policies designed to reduce language barriers and legal immigrants’ fears of receiving health benefits were successful during the period examined here. Second, despite these reductions in uninsurance, more than one in five low-income citizen children in mixed-status families are uninsured, compared with about one in eight children with citizen parents.
Third, the very low rate of employer-sponsored coverage of children in mixed-status families indicates that further improvements in coverage of these children are likely to come from public programs. Finally, no further gains in public coverage of children in mixed-status

Urban Institute

Snapshots of America’s Families III, No. 12

families will occur—and the gains documented here may be reversed—if fiscally pressed states follow the lead of Colorado and Texas. Colorado eliminated access to Medicaid and SCHIP for most legal immigrants, both adults and children (National Immigration Law Center 2003), while Texas restricted eligibility for both native-born and immigrant children and cut funding for outreach (Center for Public Policy Priorities 2003). Figures recently released by the U.S. Census Bureau (Mills and Bhandari 2003) show no further decline in uninsurance among children between 2001 and 2002, suggesting that most of the progress we see here occurred between 1999 and 2001, and that this progress may have already ended.
References
Center for Public Policy Priorities. 2003. “Texas State Budget for 2004-05 and Implications for Latinos.” Presentation to National Council of La Raza, Austin, July. http://www.cppp.org/products/testimony/presentations/prs-nclr.pdf. (Accessed September 23, 2003).
Fix, Michael, and Wendy Zimmermann. 2001. “All Under One Roof: MixedStatus Families in an Era of Reform.” International Migration Review 35(2): 397–419.
Holcomb, Pamela, Karen Tumlin, Robin Koralek, Randy Capps, and Anita Zuberi. 2003. “The Application Process For TANF, Food Stamps, Medicaid

and SCHIP.” Final Report to U.S. Department of Health and Human Services, Assistant Secretary for Policy Evaluation. Washington, D.C.: The Urban Institute. Kenney, Genevieve, Jennifer Haley, and Alexandra Tebay. 2003. “Children’s Insurance Coverage and Service Use Improve.” Snapshots of America’s Families III, No. 1. Washington, D.C.: The Urban Institute. Ku, Leighton, and Sheetal Matani. 2001. “Left Out: Immigrants’ Access to Health Care and Insurance.” Health Affairs 20(1): 247–56. Ku, Leighton, and Timothy Waidman. 2003. “How Race/Ethnicity, Immigration Status and Language Affect Health Insurance Coverage, Access to Care and Quality of Care Among the Low-Income Population.” Washington, D.C.: Kaiser Family Foundation. Mills, Robert J., and Shailesh Bhandari. 2003. “Health Insurance Coverage in the United States: 2002.” Current Population Reports. Washington, D.C.: The Census Bureau. National Immigration Law Center. 2003. “Soskin v. Reinertson: District Court Enjoins Colorado’s Termination of Immigrants’ Medicaid Eligibility.” Immigrants’ Rights Update 17(2). Los Angeles: National Immigration Law Center. Schlosberg, Claudia, and Doreena Wong. 2002. Immigrant Access to Health Benefits: A Resource Manual. Boston and Washington, D.C.: The Access Project and National Health Law Program. Schur, Claudia, and Jacob Feldman. 2001. “Running in Place: How Job Characteristics, Immigrant Status, and Family Structure Keep Hispanics Uninsured.” New York City: Commonwealth Fund and The Project HOPE Center for Health Affairs.

Figure 2. Medicaid/SCHIP and Employer-Sponsored Coverage of Low-Income Citizen Children, by Citizenship of Parents, 1999 and 2002

Medicaid/SCHIP

60
50 50.0ˆ
40 37.1

49.3ˆ
36.4

53.8ˆ
42.3

30

20

Employer-Sponsored

39.5
32.9ˇ

41.4
34.9ˇ

■ 1999 ■ 2002
26.1 22.1

Percent

10

0 All low-income citizen children

Those with citizen parents

Those with at least one
noncitizen parent

All low-income citizen children

Those with citizen parents

Those with at least one noncitizen parent

Sources: 1999 and 2002 National Survey of America's Families Notes: Low-income is defined as below 200 percent of the federal poverty thresholds. Percentage point changes are calculated from unrounded estimates for each year and may therefore differ slightly from calculations based on the rounded estimates given here. ˆ Increase between 1999 and 2002 is significant at the 0.10 level. ˇ Decrease between 1999 and 2002 is significant at the 0.10 level.

Urban Institute

Snapshots of America’s Families III, No. 12

Figure 3. Medicaid/SCHIP Coverage of Low-Income Citizen Children, by Language Used in Interview, 1999 and 2002

Percent

60

50

49.1ˆ

40 36.3

30

20

10

0 English interview

55.9ˆ
44.7
Spanish interview

■ 1999 ■ 2002

Zimmermann, Wendy, and Michael

Sources: 1999 and 2002 National Survey of America's Families

of coverage. Coverage was

Fix. 1998. “Declining Immigrant

Notes: Low-income is defined as below 200 percent of the federal

measured at the time of the survey

Applications for Medi-Cal and

poverty thresholds. Percentage point changes are calculated from

and was grouped into four

Welfare Benefits in Los Angeles

unrounded estimates for each year and may therefore differ slightly from

categories: employer-sponsored

County.” Immigration Studies

calculations based on the rounded estimates given here.

insurance (including military

Research Report. Washington,

ˆ Increase between 1999 and 2002 is significant at the 0.10 level.

coverage); Medicaid, separate

D.C.: The Urban Institute.

SCHIP, or another state program;

Zimmermann, Wendy, and Karen

other (including coverage through

Tumlin. 1999. Patchwork

Medicare, privately purchased

Policies: State Assistance for Immigrants under Welfare Reform. Washington,

coverage, and other coverage not classifiable elsewhere); and uninsurance/no

D.C.: The Urban Institute. Assessing the New Federalism Occasional Paper

coverage. Coverage is defined using a hierarchy. For example, individuals with

No. 24.

both employer-sponsored and some other form of coverage were classified as

having employer-sponsored coverage. No adjustment was made for the

Acknowledgments
The authors would like to thank Alexandra Tebay and Jane Reardon-Anderson for their research assistance and Tim Waidman, Leighton Ku, Ken Finegold, Alan Weil, and Stephen Zuckerman for all their good advice and comments.

possible undercount of Medicaid/SCHIP coverage. 3 This Snapshot reports on insurance coverage of low-income citizen children
under age 18 by the citizenship status of their parents, whereas Kenney, Haley, and Tebay (2003) reported on insurance coverage of children under age 19 by family income and race/ethnicity. Parents are defined as persons

age 18 and older living in the household with their biological, step-, or

Endnotes

adoptive child under age 18. In the few cases where a parent living in the

1 In most mixed-status families, the children are U.S. citizens but the parents

household was not identified, the respondent’s citizenship status was used.

are not. However, many mixed-status families include both citizen and non-

4 The 2.5 percentage point difference between the drop in employer-sponsored

citizen children (Fix and Zimmermann 2001). This Snapshot examines only

insurance for children of citizens and the drop for children of mixed-status

children in mixed-status families who are themselves U.S. citizens and who

families is not statistically significant at the 0.10 level.

have at least one noncitizen parent. Additionally, by “noncitizen parents” we

mean parents who are either legal or undocumented immigrants.

Randy Capps is a research associate in the Population Studies Center of the

Income was obtained for the prior calendar year. Low-income families are

Urban Institute. Genevieve Kenney is a principal research associate in the

defined as those with incomes below 200 percent of the federal poverty

Health Policy Center of the Urban Institute. Michael Fix is director of the

thresholds.

Institute’s Immigration Studies Program and a principal research associate in

2 The NSAF measures insurance coverage by inquiring about various sources of

the Population Studies Center.

coverage and then asking a verification question that confirms lack of coverage

for respondents and other household members who do not report any source

Snapshots of America’s Families III, No. 12

SNAPSH
of America's

TS3
Families

Snapshots III presents findings from the 1997,

1999, and 2002 rounds

of the National Survey of

America’s Families

(NSAF). Information on more than 100,000

people was gathered from approximately

40,000 representative households in each

round. The NSAF is part of the Assessing

the New Federalism project (ANF).

Information on ANF and the NSAF can be

obtained at http://www.urban.org/anf.

The Assessing the New Federalism project is currently supported by The Annie E. Casey Foundation, The Robert Wood Johnson Foundation, the W.K. Kellogg Foundation, The John D. and Catherine T. MacArthur Foundation, The Ford Foundation, and The David and Lucile Packard Foundation.
Alan Weil is the director of Assessing the New Federalism. Kenneth Finegold is the editor of Snapshots III. Design is by Bremmer & Goris Communications.

Assessing the New Federalism
An Urban Institute Program to Assess Changing Social Policies
Copyright © October 2003. Permission is granted to reproduce this document with attribution to the Urban Institute. The views expressed are those of the authors and do not necessarily reflect those of the Urban Institute, its board, its sponsors, or other authors in the series.
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