Survey of Income and Program Participation (SIPP) Analytic Research Small Grants Competition

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1 Survey of Income and Program Participation (SIPP) Analytic Research Small Grants Competition Gaps in Health Insurance Coverage among Mexican Immigrant Children: How Much Does Legal Status Matter? Deborah Roempke Graefe, Pennsylvania State University CONFERENCE DRAFT DO NOT CITE

2 Gaps in Health Coverage among Mexican Immigrant Children: How Much Does Legal Status Matter? Deborah Roempke Graefe Research Associate Population Research Institute Pennsylvania State University 505 Oswald Tower University Park, PA Phone: FAX:

3 Gaps in Health Coverage among Mexican Immigrant Children: How Much Does Legal Status Matter? Abstract More than 5 million U.S. children have Mexican-immigrant parents, and their presence among America s children is growing. Little is known about the effects of immigrant documentation status on the health of Mexican parents and their children, despite the fact that the U.S. Mexican-origin population is among those most likely to lack health insurance coverage and to report no regular source of medical care. Furthermore, health care for undocumented immigrants is at the forefront of current health care policy debates. For the first time, this project provides nationally representative, systematic evidence on how the health care coverage trajectories of Mexican children of immigrants (age 0 to 18) differ by their native-born, legal-immigrant, or undocumented-immigrant status. The aim of this study is to document the patterns of health insurance coverage among children in Mexican-immigrant families, comparing Mexican children of immigrants (i.e., children having at least one Mexican immigrant parent) and children with U.S.-born parents, both inter- and intra-ethnically, with particular attention to child and parent documentation status. The project uses the 1996, 2001, 200, and 2008 SIPP panels, which permits tests of the hypotheses during periods of distinct national economic growth and recession, including the current period during which the lack of health insurance coverage has grown. The longitudinal nature of SIPP survey gives a unique opportunity to document and evaluate health insurance coverage on a monthly basis (see Short and Graefe 2003), providing individual-level information on health insurance coverage. Descriptive results, including proportions experiencing transitions to and from coverage, based on life table analyses, demonstrate the patterns and trajectories for each comparison group. 1

4 Gaps in Health Coverage among Mexican Immigrant Children: How Much Does Legal Status Matter? More than 5 million U.S. children have Mexican-immigrant parents, and their presence among America s children is growing. Little is known about the effects of immigrant documentation status on the health of Mexican parents and their children, despite the fact that the U.S. Mexican-origin population is among those most likely to lack health insurance coverage and to report no regular source of medical care. Longitudinal data for four nationally representative cohorts interviewed in the 1996, 2001, 200, and 2008 Panels of the Survey of Income and Program Participation (SIPP) are used to document annual patterns of health insurance coverage among children in Mexican-immigrant families, comparing Mexican children of immigrants (i.e., children having at least one Mexican immigrant parent) and children with U.S.-born parents, with particular attention to child and parent documentation status. Specifically, this study compares 1) all Mexican children of immigrants (i.e., as a single broad group) with children having no immigrant parents (i.e., children whose parents were born in the United States); 2) all Mexican children of immigrants with race-ethnic groups of children who have nativeborn parents (i.e., Mexican-origin, other Hispanic, non-hispanic black, and non-hispanic white children of native-born parents); 3) Mexican children of immigrants across immigration-status groups (defined as U.S.-born children of undocumented parents, U.S.-born children of documented parents, immigrant children of documented parents, and immigrant children of undocumented parents); and ) Mexican children of immigrants in these immigration-status groups with the race-ethnic groups of children of U.S-born parents outlined above. This study s use of restricted-access Census-internal files of SIPP data offers a unique opportunity to identify the legal/undocumented status of the parents of these children based on parents responses to a survey question regarding immigration status. Because misinformation regarding their legal status 2

5 may be reported by some immigrants, a regression-based algorithm that was developed on the basis of this reported status together with parents personal and immigration-related characteristics is used to estimate the immigration status of Mexican immigrant parents. Mother s status combined with mothers date of immigration and child s date of birth is then used to identify the child s legal/undocumented status. Thus, this study goes beyond past studies of gaps and trajectories of health insurance coverage to document disparities in health coverage and patterns of coverage over time by parent and child immigrant documentation status for Mexican immigrants, the largest national origin group comprising immigrants to the United States. Background and Significance More than 5 million U.S. children have Mexican-immigrant parents. These children have an uncertain standing in the American health care system. It is well established that U.S. residents of Mexican origin are among the most likely to lack health insurance coverage and to report no regular source of medical care. Roughly three in ten (29%) Mexican-origin children (i.e., children with nativeborn or foreign-born parents) lack health insurance (Brown et al., 2000). However, little is known about the effects immigrant documentation status of parents and children on health care access, including health coverage trajectories and sources of coverage, which this study is designed to address. Such health care inadequacies are significant given Mexican children s growing share of the U.S. population. Mexicans, who represented almost 10% of the U.S. population in 2006 (author calculation based on Owens, 2008), have notably high fertility rates (Dye, 2008), and are expected to be a particularly large contributor to America s minority children over the next three decades (Jonsson & Rendall, 200). More than 36% of the Mexican-origin population is under age 18, representing 13% of all American children (author calculations from U.S. Bureau of the Census 2007a), and more than one-half of these are children of immigrants (Shields & Behrman, 200). In addition, an estimated one million or more Mexicans, including children and expectant mothers, immigrate to the United States 3

6 without documentation each year. Passel and Cohn (2009) estimate that approximately 27 percent of children of the U.S. almost 7 million unauthorized Mexican immigrants in 2008 were born outside the United States, giving these children an undocumented immigration status that is likely to compromise their health care. Past studies of child health coverage disparities have not considered immigration status. Although a recent examination of coverage by immigration status and country-of-origin indicates that Mexican immigrants have been significantly disadvantaged compared with other Hispanics, the finding that limited-english-proficient Hispanics were the most likely to be without coverage (Doty, 2003a) can only imply that immigration status may be important. Escarce and Kapur (2006) show that Mexicanorigin children were most likely to go without health coverage between 1997 and 2001 (one-third were uninsured compared with less than one-tenth of non-hispanic white children and less than one-fourth of Central and South American children). However, their estimates do not differentiate by either foreign/u.s.-born status or legal/undocumented status. This omission in the literature is understandable given the limited data previously available for studying immigrant children and from which immigration status can be determined. Methodological Approach Conceptual Model and Hypotheses The conceptual model for this study is based upon Glass & McAtee s multi-level framework for studying health behaviors and health outcomes in a socio-biological context (2006), which recognizes the importance of social context (in this case, immigrant documentation status) in constraining and inducing behavior. In my conceptual model, socio-cultural context defined by immigration status is expected to result in barriers to health care coverage not experienced by the majority population. I hypothesize that Mexican children of immigrants will be less likely to have health insurance coverage (public or private) and more likely to have repeated gaps in coverage than native-born children, including non-hispanic white, non-hispanic black, Mexican-origin, and other Hispanic children of

7 U.S.-born parents. Failing to compare children on the basis of immigration status masks important differences in legal access to public health coverage. I hypothesize that U.S-born Mexican children (i.e., U.S. citizen children) whose parents are undocumented will have better access health insurance coverage than immigrant children (i.e., non-u.s. citizen children) of undocumented parents. Because undocumented parents are likely to avoid situations that could reveal their status, I hypothesize that U.S-born Mexican children whose parents are documented will have better access to health insurance coverage than the U.S-born Mexican children of undocumented parents. Because of the length-of-residency requirements for public services, I hypothesize that noncitizen Mexican children of immigrants will be less likely than citizen children to have health insurance coverage and more likely to have larger gaps in coverage. Finally, because of the security provided by documented status, I hypothesize that noncitizen children of documented immigrants will be more likely than children of undocumented immigrants to have health coverage and to have fewer gaps in coverage. Sample and Data This project uses the 1996, 2001, 200, and 2008 SIPP panels, which permits tests of the hypotheses for annual patterns of health coverage. The longitudinal nature of SIPP survey gives a unique opportunity to document and evaluate health insurance coverage on a monthly basis (see Short and Graefe 2003), providing individual-level information on health insurance coverage. Whereas one can observe children for up to four years of their lives in the 1996 and 200 SIPP panels, the 2001 panel covers three years, and currently available data for the 2008 panel covers only 16 months. Thus, coverage patterns are examined in this study for the years 1996, 1997, 1998, and 1999 (using the 1996 SIPP panel); 2001, 2002, and 2003 (using the 2003 SIPP panel); 200, 2005, 2006, and 2007 (using the 2001 SIPP panel); and 2008 (using the 2008 SIPP panel). These panels provide a study sample of 2,33 Mexican children of immigrants from birth to age 18. SIPP oversamples low-income and minority areas, and comparison samples of children of native-born parents 5

8 are sufficiently large for analysis, including 2,39 native-born Mexican-origin children of native-born parents and 10,800 non-mexican Hispanic, 15,031 black, and 56,599 non-hispanic white children. About 2 percent are adolescents and 58 percent, younger than age 13, as shown in Table 1. Importantly, SIPP provides longitudinal data including a sufficient, nationally representative sample of both legal and undocumented Mexican children of immigrants. This analysis, in which Mexican children of immigrants are compared on the basis of parent and child legal status, requires access to the restricted internal files of SIPP data. These files provide the full range of responses to the question asked regarding immigration status at the time the respondent arrived in the United States, as shown by the questionnaire item in Table 2. Public use SIPP files collapse the response to this question into two categories (legal permanent resident, or other). For this study, the residual other category from the six-response version available in SIPP internal files is considered undocumented. Researchers ask this question of persons aged 15 and older at the wave 2 interview, and thus it is useful for determining parents legal status and legal status for older adolescents. For children not asked this question, information on the mother s status and date of immigration and the child s date of birth is used to determine the child s nativity and legal status for sample children. Beginning with the 200 SIPP panel, nativity status is asked directly for all respondents, including children, as part of the core data collection. The parent s immigration status measure is used to develop an algorithm for identifying her immigration status in the public use files which is based on individual characteristics including age, sex, year of immigration, and occupation (all available in SIPP). For children in two-parent families, if either parent is determined to be documented, the parents are considered to be documented; if both parents are determined to be undocumented, the parents are considered undocumented. Children not born after their mothers immigrated to the United State are considered immigrant children, and immigrant children born to undocumented mothers are also considered undocumented. Using this strategy, more than 1,300 children of Mexican immigrants (over half of children of Mexican 6

9 immigrants) are designated as having undocumented parents, 5 percent of whom are U.S. citizens (i.e., were born in the United States). Health insurance coverage, the outcome of interest, is measured in several ways, including has/does not have coverage in a particular month, patterns of coverage and coverage gaps (including continuous coverage throughout the year), source of coverage (e.g., public versus private, or Medicaid/SCHIP, private, employer-sponsored, or none), and patterns in coverage sources over time. Age of child is a critical control and stratifying measure given that eligibility for publicly provided coverage varies by age. Age is considered here as an age-group dummy variable indicating that the child is 0 to 12 years old versus 13 to 18 years. Analysis SIPP has a complex sampling design, which makes it crucial to take geographic clustering into account in the estimations of means and percentages and in the calculation of standard error, which is achieved by using the SUDAAN statistical package with SIPP-supplied stratification weights. In these descriptive analyses of insurance coverage patterns, comparisons are made on the basis of the race-ethnic, nativity, and legal status of those who have or who lack coverage. Because a series of gaps in coverage can be as important for access to routine care as a single gap in insurance coverage (Klein & Glied, 2005), patterns of coverage gaps are documented. In addition, children are compared regarding the different types of coverage and patterns of gaps in and combinations of types of coverage over time (e.g., by year). Finally, the cumulative proportions by age experiencing gains and losses of coverage are estimated based on life table analysis using a conditional multinomial logit model to estimate the health outcome event at each age. Following Guilkey and Rindfuss (1987), life tables are calculated with model-estimated coefficients to obtain cumulative proportions experiencing the event within a calendar year. Each year 1996 through 2008, except for 2000 (for which SIPP does not provide data), is considered. This strategy estimates cumulative incidence of the health-access 7

10 outcome to avoid the bias from attrition that occurs with prevalence estimates. The model for estimating hazard rates takes the general form: Logit (p t ) = β 0t + β 1t Group t. Results from these models are then presented descriptively as charts showing the cumulative experiences of the health-related outcome within the year. Differences in these patterns across the various comparison groups of children and across the four time periods represented by SIPP panels are tested by statistical comparison of intercepts and slopes. Results Patterns of Health Coverage Mexican Children of Immigrants versus Children of US-Born Parents Figure 1 shows that Mexican children of immigrants, as a whole, are at greater risk of lacking health insurance coverage and of experiencing coverage instability than native-born children generally. They also appear to be at greater risk than native-born Mexican-origin children with native-born parents, the U.S.-native race/ethnic group with greatest instability and lack of coverage. Comparing patterns of health insurance coverage for a calendar year shows that 81 percent of white and almost 70 percent of black children were covered for the full year for the period 1996 through 2008 (excluding 2000). By comparison, only 63 percent of native non-mexican Hispanic children and just over half of native Mexican-origin children were always insured throughout the year, and only 2 percent of the Mexican children of immigrants were covered all year. Thirteen percent of Mexican children of immigrants were uninsured all months of the year, nearly twice the percentage of Mexican-origin children of native parents and times the percentage of other Hispanic children. Comparatively few white and black children go without coverage for an entire year, although many of these children experience at least one gap in coverage. Still the percentage of 8

11 Mexican-origin children experiencing coverage with gaps is twice that for white children, and whereas all Mexican-origin share the same risk of a single gap in coverage, children of immigrants are twice as likely as children of native-born Mexican-origin parents to experience multiple gaps, moving in and out and in and out of coverage. Almost 60 percent of the children of immigrants go without health insurance coverage for at least some of the year, compared with under half of native Mexican-origin children, about a third of native Hispanic children, just under a third of black children, and under a fifth of white children. Nevertheless, Figure 2 shows that Mexican-origin children s experiences with health insurance coverage are similar, regardless of immigrant status, for ever-uninsured and ever-insured children. On average, children of immigrants go without insurance for 8 months of the year, whereas native Mexican-origin children who are ever uninsured go without coverage for 7 months and all other native children, for 6 months of the year. One explanation for this pattern may be that native groups tend to have more months per year of employer-sponsored coverage, as might be expected on the basis of the types of occupations their parents tend to have, and black children tend to have slightly more months of Medicaid coverage. It is interesting, however, that children of immigrants tend to be covered by Medicaid for the same average number of months as native Hispanic, including Mexican-origin, children. Figure 3 shows the percentage of children with different combinations of coverage throughout the year. Only the most frequently observed combinations are designated, with other combinations as a residual category encompassing a multitude of possible patterns of coverage types and gaps in coverage, each of which is experienced by less than 1 percent of children in the race/ethnic and nativity group. The name of each category designated begins with the first type of coverage observed, followed by the names of the other types of coverage experienced. The figure does not capture the number of transitions experienced, however. Thus, for example, 18 percent of native Mexican-origin children began the year with Medicaid coverage and became uninsured; these children may have 9

12 remained uninsured throughout the rest of the year, or may have transitioned back into Medicaid, and some who regained Medicaid coverage, may have transitioned again from Medicaid coverage to no coverage. Categories including uninsured months are shown with cross-hatching. Clearly, Hispanic children are more likely to have annual coverage patterns involving months without coverage, with Mexican-origin children more likely to do so than other Hispanics, and immigrant children more likely than Mexican-origin children with native-born parents. A similar race/ethnic and nativity gradient is seen as well in the differences in likelihood of experiencing instability in coverage, indicated by combining the colored cross-hatched sections of the bars. Mexican-origin children, in particular, appear to have a more difficult time maintaining Medicaid eligibility than other children, with 18 percent of native Mexican-origin children experiencing at least one transition from Medicaid during the year. This fraction represents half of native Mexican-origin children who started the year with Medicaid. It is less surprising that large portions of Mexican immigrant children who begin the year with Medicaid transition to a lack of coverage since many of these children have undocumented parents or are themselves not documented, making them ineligible for public health insurance in most cases. Thus the legal documentation status of these immigrant children must be examined as an important structural barrier to health coverage. Comparisons among Mexican Children of Immigrants To evaluate the importance of legal documentation status, it is important to consider both the child s and the child s parents documentation standing. Whereas the Mexican children of immigrants, as a whole, are clearly disadvantaged regarding health insurance coverage, this disadvantage may largely be explained by their lack of access to U.S. public assistance services since their parents are less likely than U.S. natives to be employed in jobs offering health care benefits. Thus, it is useful to examine these patterns of coverage by child/parent documentation category. U.S.-Born Children of Documented Parents 10

13 Native-born children of documented immigrant parents are more likely to start the year with Medicaid coverage than other Mexican-origin children, even those with native-born parents, and are more likely to remain covered by Medicaid throughout the year (23 percent; see Figure 3). Also, 33 percent have had some coverage through a parent s employer. Thus, these children have general patterns of coverage that are almost identical to those of native Mexican-origin children with native parents, and they are more likely than other immigrant children to be insured throughout all months of the year, as shown in Figure. Among those who were ever uninsured, these children experienced fewer months without coverage, and these children were covered by Medicaid for an average of 5 months, compared with 3 to months for other immigrant children (see Figure 5). Thus, not only were more of these children covered by Medicaid and employer-sponsored health insurance, they tended to be covered for more time by these sources of insurance than other immigrant children. U.S.-Born Children of Undocumented Parents As shown in Figure, in contrast to the native-born children of documented immigrant parents, native-born children of undocumented immigrants are much less likely to be insured throughout the year (32 compared with 5 percent) and are more likely to experience gaps in coverage (56 compared with 1 percent), as well as going all year without health insurance (12 compared with 5 percent). In addition, they tend to spend more months without coverage when they go without health insurance and are covered by employer- and publicly provided health insurance for fewer months, on average (see Figure 5). These patterns suggest that parent documentation status plays an important role. However, this group was covered through these sources less often than foreign-born Mexican children, including those whose parents are undocumented. Indeed, the patterns observed in Figures 3 and for foreignborn children are similar regardless of parent documentation status. The patterns revealed in these figures suggest that U.S.-born children of undocumented parents experience the greatest disadvantage of all groups when it comes to health insurance coverage, with much movement in and out of coverage (see Figure 3). 11

14 Immigrant Children of Documented Parents Whereas the patterns for foreign-born children with documented parents are quite similar to those of foreign-born children with undocumented parents, it is notable that those with documented parents are somewhat more likely to be insured all year. This finding again suggests an important role of documentation status, even though the two groups of children are equally likely to go without coverage all year (Figure ) and among the ever-uninsured, experience the same average number of months without coverage (Figure 5). However, these children are more likely to receive coverage through their parent s employment (Figure 3), with an average months of employer-sponsored coverage, compared with 3 months experienced by immigrant children with undocumented parents (Figure 5). Immigrant Children of Undocumented Parents As noted above, immigrant children of undocumented parents have patterns of coverage which are quite similar to foreign-born children of documented immigrants, although they are somewhat more likely to experience coverage instability. They are just as likely to go without coverage for the entire year, however, and tend to experience the same number of months, on average, without coverage when they go without it. Perhaps surprisingly, their parents report their being covered by Medicaid, on average, months of the year, more than for native-born children of undocumented immigrants or for foreign-born children of documented parents, despite their apparent legal ineligibility for public benefits. Transitions into and out of Health Coverage Another way to examine the health insurance coverage experiences of individuals over time is to calculate the percentages expected to transition to coverage following an uninsured period or the percentages expected to lose coverage during the year. Figures 6 and 7 show the cumulative percentages of children who had an uninsured spell who are expected to gain insurance coverage throughout the year. Figure 6 shows that, although uninsured Mexican immigrant children gain coverage more slowly than children with native-born parents during the first third of a calendar year, 12

15 by the fifth month more have gained coverage than is seen for native Mexican-origin children with native-born parents (around a third compared with about 28 percent). Within a year, half of Mexican immigrant children transition into coverage, compared with around 60 percent of white and non- Mexican Hispanic children and only 0 percent of native Mexican-origin children. Table 3 presents parameter estimates from event history models predicting transition to coverage. Model 1 shows that children of immigrants (the reference category) are less likely to gain coverage than native non-mexican-origin children and are significantly more likely to gain coverage than native Mexican-origin children. These relationships remain significant with adjustments for child age and year of observation (model 2), although the effect of age differs for children of immigrants such that they are increasingly less likely to gain coverage as they grow older (model ) and the effect of year of observation is opposite that for native children (model 5). Descriptive statistics on the patterns of coverage among Mexican immigrant children which were discussed above indicate, however, that there will be heterogeneity among this group in the proportions who gain coverage over time. Figure 7 shows that native-born children with a documented immigrant parent are more likely than other children of Mexican immigrants to gain coverage within the year; model 6 of Table 3 shows that this difference is statistically significant. Half of these children gain coverage within the first 6 months of the year, and two-thirds are covered by the end of the year. Foreign-born children and native-born children with an undocumented parent gain coverage at the same pace, with around 5 percent transitioning into coverage by the end of the year. Model 6 of Table 3, which adjusts for child age and observation year, indicates that these groups are not significantly different. A model testing interactions of child age with immigrant group (not shown) indicates that the effect of age does not vary by immigrant documentation status. Nevertheless, the effects of documentation status and nativity differ across observation years (model 7, Table3). Of course, these analyses do not tell us whether those who have health insurance remain covered. 13

16 Figures 8 and 9 show cumulative percentages of insurance-covered children who lose coverage within the year. Non-Hispanic white children are least likely to lose health insurance coverage; just over 1 in 10 who are covered by health insurance become uninsured within a year s time (Figure 8). In contrast, nearly a quarter of non-white children who have health insurance experience a loss of coverage within the year. The experiences of Mexican immigrant children mirror that of other minority children in this regard, although adjustment for age and year of observation, shown in model 2 of Table, reveals that children of immigrants are more likely to lose coverage than most nativeborn children, in part because they are more likely to lose coverage as they grow older (model ). As with transitions into coverage, the effect of observation year on the probability of a transition from coverage varies for immigrant and non-mexican-origin native-born children (model 5). Although native-born children of documented immigrants are shown by Figure 9 to be at an advantage compared with most other children of immigrants in maintaining health insurance coverage, foreign-born children with a documented parent are equally advantaged. In part, the advantage of native-born children of documented immigrants can be explained by the finding that they are less likely to lose coverage as they age relative to foreign-born children. Whereas almost one third of these children lose coverage within a year of being covered, 36 percent of foreign-born children with undocumented parents and well over a third of native-born children with an undocumented parent lose coverage within a year. Again, native-born children of undocumented parents appear at greatest disadvantage. Conclusion The aim of this study is to examine differences in Mexican-origin children s likelihood of having health insurance coverage and in patterns in coverage by documentation status and nativity. Of course, a first step is to identify nativity and parent documentation status for immigrant children. Using SIPP s wave 2 migration topical module questions, children of immigrant parents were identified and categorized according to parents immigration status when they entered the country. This strategy 1

17 resulted a sub-sample of Mexican-origin children which may over-represent children of undocumented parents about 56 percent are identified as having undocumented parents, the overwhelming majority of whom were born in Mexico. Contrary to Passel s and Cohn s (2009) estimate that more than two thirds of the children of unauthorized Mexican immigrants in 2008 were U.S. born, surprisingly few (5. percent of children of immigrants) Mexican-origin children are identified as native-born to undocumented parents between 1996 and Despite the potential error in documentation-status categorization, the findings regarding health insurance coverage of these children provide overwhelming support for the hypothesized effects of documentation status and nativity in general. Importantly, the usual expected error would be to incorrectly identify undocumented individuals as documented because of the social response bias for an immigrant to respond that he or she is in the country legally. If children of undocumented parents were incorrectly categorized as having documented parents, a larger proportion of the immigrant sub-sample would be expected to be categorized as having a documented parent, and results would be biased toward smaller differences between immigrant subgroups. Being foreign born and having undocumented immigrant parents are expected to result in barriers to health care coverage not experienced by the majority population. The hypothesis that Mexican children of immigrants are less likely to have health insurance coverage and more likely to have repeated gaps in coverage than native-born children, including non-hispanic white, black, Mexicanorigin, and other Hispanic children of U.S.-born parents is supported, consistent with Escarce s and Kapur s (2006) finding that Mexican-origin children were most likely to go without health coverage between 1997 and 2001 compared with other children in the U.S. As a whole, children of Mexican immigrants are almost twice as likely as their Mexican-origin counterparts with U.S.-born parents to go all year without health insurance coverage, a difference that remains significant with adjustments for age and period measured as the year of observation. In addition, they are more likely to go longer periods without coverage when they lack health insurance and they experience more gaps in coverage. 15

18 Nevertheless, these children do have periods with health insurance coverage, from both public and private sources. Although native white and black children spend less time uninsured because of their greater access to both employer-supported and publicly-provided health insurance, Mexican children of immigrants are covered by Medicaid on average as many months as are all native Hispanic children and by employer-sponsored coverage the same amount of time on average as native Mexican-origin children. When uninsured in any year, they are more likely than native-mexican-origin children to become insured that year. Yet they are also just as likely to lose coverage within a year. These findings are surprising since many children of Mexican immigrants are expected to be disadvantaged by their parents undocumented immigration status. Failure to compare children on the basis of immigration status is expected to mask important differences in legal access to public health coverage as well as potential differences in access to coverage through their parent s workplace. Indeed, the native-born children of documented immigrants have patterns of coverage that are almost identical to those of native Mexican-origin children and foreign-born children of documented immigrants experience have more stable coverage than children of undocumented parents. In addition, children of documented immigrants are more likely to be covered all year and to have fewer gaps in coverage than children of undocumented immigrants. Thus, the hypothesis that U.S-born Mexican children whose parents are documented will have better access to health insurance coverage than the U.S-born Mexican children of undocumented parents is supported. However, the hypothesis that U.S-born Mexican children (i.e., U.S. citizen children) whose parents are undocumented will have better access health insurance coverage than immigrant children (i.e., non-u.s. citizen children) of undocumented parents is not supported by this study. This finding is surprising since U.S.-born children have a legal right to public benefits. However, if undocumented parents avoid situations that could reveal their status, they may fail to take advantage of their children s legal rights as long as there is no imposing medical need. Further 16

19 research is needed to examine this question on the basis of child health status as well as sources of medical care utilized. Indeed, the security provided by documented status leads to the hypothesis that noncitizen (foreign-born) children of documented immigrants will be more likely than children of undocumented immigrants to have health coverage and to have fewer gaps in coverage, which is supported. Because of the length-of-residency requirements for public services, I hypothesized that noncitizen Mexican children of immigrants will be less likely than citizen children to have health insurance coverage and more likely to have larger gaps in coverage. Indeed, foreign-born children of immigrants are less likely to be covered throughout the year and have longer periods without coverage on average than native-born children of immigrants. In sum, immigrant-parent legal status matters, even more than the child s own nativity, for gaining and keeping health coverage. Current health care reforms are not likely to change this scenario unless states choose to overlook parent s immigration status in the health coverage of children. Still, more research is needed to better understand the circumstances under which immigrant children s gaps in coverage have occurred. Furthermore, more study is needed to understand why children of native Mexican-origin parents, and native Hispanic parents generally, are comparatively disadvantaged among U.S. citizens when it comes to health insurance coverage. 17

20 References Brown, E. Richard, Ojeda, Victoria D., Wyn, Richard, & Levan, Rebecka Racial and ethnic disparities in access to health insurance and health care. Los Angeles, CA: UCLA Center for Health Policy Research. Doty, Michele M Insurance, access, and quality of care among Hispanic populations: 2003 Chartpack. New York: The Commonwealth Fund, October. Available at (October 9, 2008). Dye, Jane Lawton Fertility of American women: Current Population Reports, P Washington, DC: U.S. Census Bureau. Escarce, J. J., & Kapur, K Access and quality of health care. Pp in Tienda, M., and Mitchell, F. (eds), Hispanics and the Future of America. Washington, DC: National Academies Press. Guilkey, D. K. & Rindfuss, R. R Logistic regression multivariate life tables: a communicable approach, Sociological Methods and Research, 16(2): Jonsson, Stefan H., & Rendall, Michael, S The Fertility Contribution of Mexican Immigration to the United States. Demography, 1: Klein, Katheryn, & Glied, Sherry A Entrances and exits: Health Insurance churning, Issue Brief, vol. 1. New York: The Commonwealth Fund. Available at (October 9, 2008). Glass, T. A., & McAtee, M. J Behavioral science at the crossroads in public health: Extending horizons, envisioning the future. Social Science & Medicine, 62: Office of Immigration Statistics yearbook of immigration statistics. Washington, DC: Department of Homeland Security. Owens, Anna M Hispanics in the United States. Washington, DC: Ethnicity and Ancestry Branch, Population Division, U.S. Census Bureau. Available at 6.pdf. Shields, Margie K., & Behrman, Richard E Children of immigrant families: analysis and recommendations. The Future of Children, 1(2): -15. Short, Pamela Farley, and Graefe, Deborah Roempke. Battery-powered Health Insurance? Stability in Coverage of the Uninsured. Health Affairs, 22(6): U.S. Bureau of the Census The American community Hispanics: 200. American Community Survey Reports, ACS-03. Washington, DC: U.S. Census). 18

21 Race/Ethnicity Children of Native-born Non-Hispanic White Black Non-Mexican Hispanic Mexican Children of Mexican Immigrants Native-born, Documented Parent Native-born, Undocumented Parent Foreign-born, Documented Parent Foreign-born, Undocumented Parent Age Group 0 to 12 years 13 to 18 years Table 1. Descriptive Statistics for Study Sample. Unweighted n 8,779 56,599 15,031 10,800 2,39 2, ,223 Percentage of Total Sample (weighted) Percentage of Immigrant Child Sample (weighted) 52, , Total 87, % Table 2. SIPP Survey Question Regarding Immigration Status. When [fill TEMPNAME] moved to the United States to live, what was [fill PTEMPNAME] immigration status? (1) Immediate relative or family sponsored permanent resident (2) Employment-based permanent resident (3) Other permanent resident () Granted refugee status or granted asylum (5) Non-immigrant (e.g., diplomatic, student, business, or tourist visa) (6) Other 19

22 Table 3. Logistic regression coefficients from event history models predicting transition from being uninsured to being covered by health insurance. Full Sample Mexican-origin Sample (n=02,320 person-months) (n=61,702 person-months) Model 1 Model 2 Model 3 Model Model 5 Model 6 Model 7 Intercept -2.8** -3.1** ** -2.8** -3.2** -2.0** Race/Ethnicity & Nativity Native Non-Mexican White Black Hispanic Native Mexican Child of Immigrant Native, Documented Parent Native, Undocumented Parent Foreign-born, Documented Parent Foreign-born, Undocumented Parent.30**.39**.21** -.27** REF.35**.3**.22** -.13** REF REF -.6** -.53** REF -.5** -.0** REF -.66** -.28** -.11* -1.18**.** REF * REF Age -.03** -.03** -.03** -.03** -.0** -.0** Year Year 2 Year 3 Interactions with Age Native Mexican*Age Child of Immigrant*Age Interactions with Year Native Mexican*Year Native Mexican*Year 2 Native Mexican*Year 3 Child of Immigrant*Year Child of Immigrant*Year 2 Child of Immigrant*Year 3 Native, Documented Parent*Year Native, Documented Parent*Year 2 Native, Documented Parent*Year 3 Native, Undocumented Parent*Year Native, Undocumented Parent*Year 2 Native, Undocumented Parent*Year 3 Foreign-born, Documented Parent*Year Foreign-born, Documented Parent*Year 2 Foreign-born, Documented Parent*Year 3 Note: All models control for time in model. *p.05 **p.01.33** -.05**.002**.33** -.05**.002**.3** -.05**.002** **.3** -.05**.002** **.10** -.006**.32** -.0** **.35** -.03** 1.5** -.2**.03** 2.** -.67**.05** **.03**.93** -.26**.02** 20

23 Table. Logistic regression coefficients from event history models predicting transition from being insured to being uninsured. Full Sample (n=1,932,578 person-months) Mexican-origin Sample (n=103,579 person-months) Model 1 Model 2 Model 3 Model Model 5 Model 6 Model 7 Model 8 Intercept -3.7** -3.8** -.** -.** -.** -3.1** -3.2** -3.8** Race/Ethnicity & Nativity Native Non-Mexican White Black Hispanic Native Mexican Child of Immigrant Native, Documented Parent Native, Undocumented Parent Foreign-born, Documented Parent Foreign-born, Undocumented Parent -.78** -.1**.01.08** REF -.81** -.17** ** REF REF.66**.90** REF.8**.79** REF 1.7** 1.2** -.22* ** -.22** REF -.21*.50*.7** -.13 REF.99** * REF Age -.02** -.02** -.032** -.02** -.00** Year Year 2 Year 3.27** -.0**.002**.25** -.0**.001**.25** -.0**.001**.27** -.0**.002** * Interactions with Age Native Mexican*Age Child of Immigrant*Age Native, Documented Parent*Age Native, Undocumented Parent*Age Foreign-born, Documented Parent*Age Interactions with Year Native Mexican*Year Native Mexican*Year 2 Native Mexican*Year 3 Child of Immigrant*Year Child of Immigrant*Year 2 Child of Immigrant*Year 3 Native, Documented Parent*Year Native, Documented Parent*Year 2 Native, Documented Parent*Year 3 Native, Undocumented Parent*Year Native, Undocumented Parent*Year 2 Native, Undocumented Parent*Year 3 Foreign-born, Documented Parent*Year Foreign-born, Documented Parent*Year 2 Foreign-born, Documented Parent*Year 3 Note: All models control for time in model. *p.05 **p.01.02**.01** -.51**.08** -.00** -.28**.06** -.00** * **.17* -.01* -1.0*.26** -.02** **.27** -.02** 21

24 Figure 1. Percentage of Children with Gaps in Annual Insurance Coverage, by Race/Ethnic Group, Mexican Children of Immigrants Native Mexican-origin Children Native Hispanic Children Native Black Children Native White Children % 10% 20% 30% 0% 50% 60% 70% 80% 90% 100% Always Insured Always Uninsured One Gap in Insurance Coverage Multiple Gaps in Insurance Coverage 0

25 Figure 2. Annual Average Number of Months Uninsured among Ever-Uninsured Children and Average Months of Employer-Provided and Medicaid Coverage, by Race/Ethnicity, Native White Children Native Black Children Native Hispanic Children Native Mexican-origin Children Mexican Children of Immigrants Months Uninsured Months of Employer-provided Coverage Months of Medicaid 1

26 Figure 3. Most Frequently Observed Annual Coverage Combinations, , by Race/Ethnicity and Nativity. Foreign-born Children of Undocumented Immigrant Parents Medicaid Only Foreign-born Children of Documented Immigrant Parents Medicaid-Employer Medicaid-Uninsured Native-born Children of Undocumented Immigrant Parents Medicaid-Employer-Uninsured Medicaid-Nonemployer-Uninsured Native-born Children of Documented Immigrant Parents Employer Only Employer-Medicaid Native Mexican-origin Children Employer-Uninsured Employer-Uninsured-Medicaid Native Hispanic Children Uninsured Only Uninsured-Medicaid Uninsured-Employer Native Black Children Uninsured-Medicaid-Employer Other Combinations Native White Children % 10% 20% 30% 0% 50% 60% 70% 80% 90% 100% 2

27 Figure. Gaps in Annual Health Insurance Coverage among Mexican-origin Children, Foreign-born Children of Undocumented Immigrant Parents Foreign-born Children of Documented Immigrant Parents Native-born Children of Undocumented Immigrant Parents Native-born Children of Documented Immigrant Parents Native Mexican-origin Children % 10% 20% 30% 0% 50% 60% 70% 80% 90% 100% Always Insured Always Uninsured One Gap in Insurance Coverage Multiple Gaps in Insurance Coverage 3

28 Figure 5. Annual Average Number of Months Uninsured among Ever-Uninsured Children and Average Number of Months with Employer-provided and Medicaid Coverage, by Immigrant Status, Native Mexican-origin Children Native-born Children of Documented Immigrant Parents Native-born Children of Undocumented Immigrant Parents Foreign-born Children of Documented Immigrant Parents Foreign-born Children of Undocumented Immigrant Parents Months Uninsured Months of Employer-provided Coverage Months of Medicaid

29 Figure 6. Cumulative Percentages of Uninsured Childern Who Become Insured within a Year, , by Race/Ethnicity and Nativity White Mexican Immigrant Black Hispanic Native Mexican Months 5

30 Figure 7. Cumulative Percentages of Uninsured Children of Mexican Immigrants Who Become Insured within a Year, , by Documentation Status Native-born with a Documented Parent 0 30 Native-born with Undocumented Parent Foreign-born with a Documented Parent Foreign-born with Undocumented Parent Month 6

31 30 Figure 8. Cumulative Percentages of Insured Children Who Become Uninsured within a Year, , by Race/Ethnicity and Nativity White Mexican Immigrant Black Hispanic Native Mexican Month 7

32 Figure 9. Cumulative Percentages of Insured Children of Mexican Immigrants Who Become Uninsured within a Year, , by Documentation Status Native-born with a Documented Parent Native-born with Undocumented Parent Foreign-born with a Documented Parent Foreign-born with Undocumented Parent Month 8