Trends in Disparities in Low-Income Childrens

Health Insurance Coverage and Access to Care

by Family Immigration Status
Marian Jarlenski, PhD, MPH; Julia Baller, PhD; Sonya Borrero, MD, MS;
Wendy L. Bennett, MD, MPH
From the Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pa (Dr
Jarlenski); Center for Womens Health Research and Innovation, University of Pittsburgh, Pittsburgh, Pa (Drs Jarlenski and Borrero);
Mathematica Policy Research, Washington DC (Dr Baller); Division of General Internal Medicine, University of Pittsburgh School of Medicine,
Pittsburgh, Pa (Dr Borrero); Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pa (Dr Borrero);
Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, Md (Dr Bennett); and Department of
Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Md (Dr Bennett)
The authors declare that they have no conflict of interest.
Address correspondence to Marian Jarlenski, PhD, MPH, Department of Health Policy and Management, University of Pittsburgh Graduate
School of Public Health, 130 DeSoto St, A647, Pittsburgh, PA 15261 (e-mail: marian.jarlenski@pitt.edu).
Received for publication May 27, 2015; accepted July 25, 2015.

ABSTRACT
OBJECTIVE: To examine time trends in disparities in lowincome childrens health insurance coverage and access to
care by family immigration status.
METHODS: We used data from the National Survey of Childrens Health in 2003 to 20112012, including 83,612 children
aged 0 to 17 years with family incomes <200% of the federal
poverty level. We examined 3 immigration status categories:
citizen children with nonimmigrant parents; citizen children
with immigrant parents; and immigrant children. We used
multivariable regression analyses to obtain adjusted trends in
health insurance coverage and access to care.
RESULTS: All low-income children experienced gains in
health insurance coverage and access to care from 2003 to
20112012, regardless of family immigration status. Relative
to citizen children with nonimmigrant parents, citizen children
with immigrant parents had a 5 percentage point greater increase in health insurance coverage (P .06), a 9 percentage
point greater increase in having a personal doctor or nurse (P

< .01), and an 11 percentage point greater increase in having

no unmet medical need (P < .01). Immigrant children had
significantly lower health insurance coverage than other groups.
However, the group had a 14 percentage point greater increase
in having a personal doctor or nurse (P < .01) and a 26 percentage point greater increase in having no unmet medical need (P
< .01) relative to citizen children with nonimmigrant parents.
CONCLUSIONS: Some disparities in access to care related to
family immigration status have lessened over time among children in low-income families, although large disparities still
exist. Policy efforts are needed to ensure that children of immigrant parents and immigrant children are able to access health
insurance and health care.

WHATS NEW

the child population, they represent nearly half (42%) of

the uninsured child population.6 Children in immigrant families have lower access to care relative to those in nonimmigrant families, even after controlling for health status and
health insurance coverage.7,8 Prior research has found a
relationship between parents health insurance coverage
and childrens coverage and access to care in low-income
families,9,10 suggesting that it is important to study
childrens health care in the context of their families. In
the present study, we add to the knowledge about health
insurance coverage and access to care among children in
immigrant families in 3 ways. First, we use 3 waves of
data spanning a 9-year time period to study time trends. Second, we examine several policy-relevant measures of both
health insurance and access to care. Third, we compare children in nonimmigrant families to children with immigrant
parents and immigrant children.

KEYWORDS: access to care; disparities; health insurance; immigrant

ACADEMIC PEDIATRICS 2015;-:18

Over a time period of 9 years, some disparities in health

insurance coverage and access to care related to family
immigration status lessened. Immigrant children
continue to have significantly lower insurance coverage
and access to care, however.
A MAJOR POLICY goal in the United States has been to
achieve universal health insurance coverage among lowincome children.1 Improved access to health insurance
coverage for children in low-income families in the United
States has been shown to increase access to care, reduce
childhood mortality, and facilitate long-term educational
gains.25 However, large disparities in insurance coverage
and access to care exist by family immigration status.
Although children in immigrant families represent 24% of
ACADEMIC PEDIATRICS
Copyright 2015 by Academic Pediatric Association

Volume -, Number -- 2015

JARLENSKI ET AL

Amid the sweeping health reforms being implemented

under the Affordable Care Act (ACA), there are several reasons why low-income immigrant families continue to face
significant barriers to coverage.11,12 First, undocumented
immigrants are excluded from public coverage under
Medicaid or the Childrens Health Insurance Program
(CHIP).13 Second, about half of states lack Medicaid/CHIP
coverage for low-income children who are legally residing
but have been in the United States for <5 years.14 Third, families in which different family members have different immigration status face a complex array of insurance program
eligibility rules based on immigration status and income.15
Finally, news media reports have recounted instances in
which individuals have been eligible for insurance programs
but remained uninsured for fear of discovery of an undocumented immigrant family member.16
In this context, it is important to understand disparities in
childrens health insurance coverage and access to care by
family immigration status. No prior research, however, has
examined how disparities in childrens health insurance
coverage and access to care by family immigration status
have changed over time. In the present study, we examine
time trends in disparities related to family immigration status on several measures of health insurance and access to
care. Findings provide important baseline information to
help understand effects of the ACA on health insurance
and access to care among immigrant populations.

METHODS
DATA AND STUDY POPULATION
We obtained data from of the National Survey of Childrens Health (NSCH) in all available years: 2003, 2007,
and 20112012.1719 The NSCH collects data about
childrens health; health insurance coverage; access to
and quality of care; and family, neighborhood, and social
context.20,21 The NSCH is a cross-sectional, nationally
representative telephone survey of US families who have
children ages 0 to 17 at the time of the survey. The surveys
included land-line telephone interviews only in 2003 and
2007, and a cellular telephone component was added in
20112012. In addition to English, the NSCH is administered in Spanish, Mandarin, Cantonese, Vietnamese, or
Korean (71% of the population speaking a language other
than English at home uses 1 of those 5 languages22). On
behalf of a randomly sampled child in the family, a parent
or guardian reports information about health and health
care of the sampled child and other family members.
Response rates were 55.3% in 2003,21 46.7% in 2007,20
and 38.2% in 20112012.23 Each year of the NSCH data
set includes final survey weights that adjust the survey responses to reflect the noninstitutionalized population of
children ages 0 to 17 in each state and the District of
Columbia. NSCH data collection procedures are standardized across years, and many questionnaire items remain the
same, so that multi-year analyses can be performed. We
combined data from the 3 waves of the survey together

ACADEMIC PEDIATRICS

and maintained the appropriate survey weights specific to

each year, to create a pooled cross-sectional data set.
Our study included NSCH data on a total of 83,612
children with family incomes <200% federal poverty
level (FPL), which comprises 42% of all respondents.
This study population includes 28,887 respondents in
2003, 26,134 respondents in 2007, and 28,591 respondents in 20112012. Defining low-income as <200%
FPL allowed us to examine insurance coverage overall
and public coverage via Medicaid/CHIP because the majority of these children in this income range would be
eligible for public coverage in their state of residence in
our study time period.2426
MEASURES
Our outcomes included 3 dichotomous measures of childrens health insurance coverage: having any health insurance coverage at the time of the survey, having Medicaid/
CHIP coverage at the time of the survey, and having continuous health insurance coverage throughout the prior 12
months. Specifically, the NSCH asks if, at the time of the
survey, a child had any kind of health coverage, and if
so, if the coverage is through Medicaid or CHIP. The survey separately asks whether, during the prior 12 months,
there was any time when the child lacked health insurance
coverage; we used this variable to define continuous health
coverage.
We also included 3 dichotomous outcome measures of
childrens access to care: having a personal doctor or nurse;
having any preventive care use during the prior 12 months;
and not having any unmet medical need during the prior 12
months. These questions were asked in all 3 waves of the
NSCH data. A personal doctor or nurse is defined as a
health professional who knows [a] child well and is
familiar with [a] childs health history. This can be a general doctor, a pediatrician, a specialist doctor, a nurse practitioner, or a physician assistant. The NSCH also asked if a
child had ever accessed preventive health care in the
prior 12 months. The NSCH data set includes a derived variable indicating the presence of unmet health needs based
on several questions about whether a child had delayed
medical care, or medical, dental, or mental health needs
that were unmet in the prior 12 months.
The independent variable of interest was childrens family immigration status. The NSCH asks whether childrens
parents were born in the United States (including biological, foster, adoptive, or step-parents); it also asks whether
children were born in the United States. We created 3 family immigration status categories: citizen children with
nonimmigrant parents (both child and parents born in the
United States); citizen children with at least 1 immigrant
parent (child born in the United States but at least 1 parent
born outside the United States); and immigrant children
(child born outside of the United States, regardless of
where parents were born). Although we are able to identify
US citizenship for children or parents born in the United
States, the data do not identify whether immigrants have
become naturalized citizens, have legal status, or are

ACADEMIC PEDIATRICS

undocumented. To examine time trends, we also included

an indicator variable for each of the 3 survey years
(2003, 2007, or 20112012).
In all analyses, we controlled for covariates that are
likely to confound the relationship between immigration
status and health insurance and access to care. Childlevel covariates included sex, age, race, ethnicity, and
health status. Family-level covariates included family
structure (child living with 2 biological parents, biological
and step-parents, single mother, or other), having a primary
household language other than English, parental employment status, and parental educational attainment. To control for time-invariant state-specific characteristics, we
included indicator variables for each childs state of residence.
Less than 3% of data were missing for all covariates
except for race. A large proportion of data on race was
missing for children with immigrant parents (28.1%
missing) and immigrant children (31.3% missing),
compared to children with nonimmigrant parents (3.0%
missing). (In contrast, <2% of data were missing for Hispanic ethnicity.) In exploratory data analyses, missing race
was statistically significantly associated with study outcomes. To address missing data we implemented multiple
imputation techniques with a flexible multinomial regression model to impute missing race.27 Detailed multiple
imputation methods, along with a comparison of estimates
using the 20 imputed data sets to estimates using an indicator variable for missing race, are shown in the Online
Appendix. Briefly, we created 20 complete data sets with
imputed race values that were generated on the basis of
the distribution of observed data. Our final analyses were
then obtained from combining estimates from the 20
imputed data sets.28
STATISTICAL ANALYSES
First, we conducted descriptive statistics to characterize
the study population, stratified by family immigration status (citizen children with nonimmigrant parents, citizen
children with at least 1 immigrant parent, and immigrant
children). We tested for significant differences between
characteristics by familys immigration status using t-tests
for continuous variables and chi-squared tests for categorical variables. Next, to obtain adjusted time trends in health
insurance and access to care, we conducted multivariable
logistic regression analyses on our 20 imputed data sets
and obtained combined estimates. We ran 6 regression
models, one for each of our outcomes. We included interaction terms between immigration status and each year to
test for significant differences in time trends by childrens
family immigration status.
We obtained predicted probabilities from our regression
models of outcomes in each year for each study group. Predicted probabilities are calculated from predictions from
the regression model, and represent the mean probability
for each value of childrens family immigration status (citizen children with nonimmigrant parents, citizen children
with at least 1 immigrant parent, and immigrant children)

INSURANCE COVERAGE AND IMMIGRATION STATUS

while accounting for effects of covariates. All analyses

were performed using Stata version 13 (StataCorp, College
Station, TX, USA), incorporating sampling weights
included in NSCH data and using the multiple imputation
and survey commands to produce the appropriate confidence intervals.
This research is based on analyses of existing, deidentified, publicly available data sets and is exempt from institutional review board review.

RESULTS
Weighted descriptive characteristics of our study sample
across all years, stratified by family immigrant status, are
shown in the Table. Large and statistically significant disparities exist on all measures of health insurance coverage
and access to care. Although 91.4% of citizen children with
nonimmigrant parents had health insurance coverage at the
time of the survey, 86.0% of citizen children with immigrant parents had coverage, and only 53.8% of immigrant
children had coverage (P < .001). Similarly, 85.7% of citizen children with nonimmigrant parents had a personal
doctor or nurse, relative to 81.3% of citizen children with
immigrant parents and 57.9% of immigrant children (P
< .001). Generally, citizen children with immigrant parents
and immigrant children had worse health status than citizen
children with nonimmigrant parents. Citizen children with
immigrant parents and immigrant children were more
likely to live with both biological parents in the home,
and had parents with lower educational attainment, relative
to citizen children with nonimmigrant parents.
HEALTH INSURANCE COVERAGE
Results from multivariable regression models show that,
over the study period of 9 years, all low-income children
experienced increases in the predicted probability of having health insurance coverage, regardless of family immigration status (Fig. 1). Disparities between citizen
children with immigrant parents and citizen children with
nonimmigrant parents in having health insurance coverage
at the time of the survey decreased from 2003 to 2007 and
from 2007 to 20112012. Large and significant immigration disparities between immigrant children and citizen
children persisted, however.
From 2003 to 20112012, citizen children with immigrant parents had a 7.9 percentage point increase in the
probability of having any health insurance coverage, and
immigrant children had a 13.3 percentage point increase
in the predicted probability of having any health insurance
coverage, compared to a 2.9 percentage point increase
among citizen children with nonimmigrant parents
(Fig. 1A). Relative to citizen children with nonimmigrant
parents, the increase in health insurance coverage,
comparing 20112012 to 2003, was greater among citizen
children with an immigrant parent (P .06). Citizen children had far higher predicted probabilities of being
enrolled in Medicaid/CHIP insurance coverage in all survey years, relative to immigrant children (Fig. 1B). The

JARLENSKI ET AL

ACADEMIC PEDIATRICS

Table. Weighted Descriptive Characteristics of Children in Low-Income Families by Immigration Status, National Survey of Childrens Health,
2003, 2007, and 20112012
Characteristic
Weighted N
Unweighted N
Health insurance coverage, %
Any health insurance
Medicaid/CHIP
Continuous coverage
Access to care, %
Personal doctor or nurse
Preventive care use
No unmet medical need
Demographics and health status
Mean age
Race, %
White
Black
Other/multiple races
Hispanic ethnicity
Health status, %
Excellent
Very good
Good
Fair
Poor
Family characteristics
Family structure, %
Biological parents
Biological and stepparents
Single mother
Other
Language not English, %
Parental employmentk, %
Parental education, %
Less than high school
High school diploma
More than high school

Citizen Children,
Nonimmigrant Parents
56,545,315
65,208

Citizen Children,
Immigrant Parent
20,752,644
14,586

Immigrant Children
5,021,063
3,818

P*

91.4
60.9
82.1

86.0
65.8
76.0

53.8
34.8
45.3

<.001
<.001
<.001

85.7
82.2
86.9

81.3
79.8
87.8

57.9
63.3
77.8

<.001
<.001
<.001

8.3

7.2

11.2

<.001

60.9
28.5
10.6
11.6

63.0
9.1
27.9
79.1

61.3
11.1
27.5
76.2

<.001

54.1
27.3
14.3
3.4
0.6

39.1
23.1
29.1
8.0
0.8

34.2
22.2
32.2
10.8
0.6

<.001

41.7
10.5
39.4
8.5
2.0
77.0

71.6
5.8
20.8
1.8
73.1
74.7

65.4
9.4
20.9
4.3
83.5
73.1

<.001

14.2
41.3
44.5

46.4
30.0
23.6

44.5
25.9
30.0

<.001

<.001

<.001
.005

CHIP indicates Childrens Health Insurance Program.

Low income was defined as having a household income <200% of the federal poverty level at the time they participated in the survey. Survey weights applied to all proportions.
*Differences between children with different immigration status tested using t tests for continuous variables and chi-square tests for categorical variables.
Continuous health insurance coverage throughout the past 12 months.
Missing race was imputed using multiple imputation.
Indicates that the primary language spoken in the household is other than English.
kAt least 1 adult in the household employed for at least 50 of the prior 52 weeks.

predicted probability of having Medicaid or CHIP

coverage at the time of the survey increased from 2003
to 20112012 among all children, with no significant differences in time trends by immigration status. Similarly,
citizen children, regardless of whether their parents were
immigrants, had far higher predicted probabilities of having continuous health insurance coverage throughout the
prior 12 months, relative to immigrant children (Fig. 1C).
No significant differences in time trends were observed
by family immigration status.
ACCESS TO CARE
In terms of access to care, the multivariable regression
models show that all low-income children experienced
gains from 2003 to 2007, regardless of family immigration
status (Fig. 2). Additionally, disparities in the probability of

having a personal doctor or nurse and having no unmet

health need by family immigration status decreased over
time.
Relative to citizen children with nonimmigrant parents,
the predicted probability of having a personal doctor or
nurse increased more rapidly from 2003 to 20112012
among citizen children with an immigrant parent (17.4 percentage point increased vs 8.8 percentage point increase, P
< .01) (Fig. 2A). Among immigrant children, the predicted
probability of having a personal doctor or nurse increased
22.5 percentage points from 2003 to 20112012, although
the increase over time was not significantly different from
citizen children with nonimmigrant parents (Fig. 2A). The
predicted probability of having any preventive care visit in
the prior 12 months increased over time among all children, although we did not observe significant differences

ACADEMIC PEDIATRICS

INSURANCE COVERAGE AND IMMIGRATION STATUS

Figure 1. Predicted probabilities of health insurance coverage among low-income children by family immigration status, 2003, 2007, and
20112012. (A) Health insurance coverage. (B) Medicaid/CHIP coverage. (C) Continuous health insurance coverage. Low-income is defined
as family income <200% of the federal poverty level. Predicted probabilities are from multivariable logistic regression controlling for childrens
age, sex, race, ethnicity, health status, family structure, family language, parents employment and education, and state of residence.

in time trends by family immigration status (Fig. 2B). From

2003 to 20112012, immigration-related disparities in the
probability of having no unmet health need decreased, with
most of the decrease in disparities occurring from 2003 to
2007 (Fig. 2C). Relative to citizen children with nonimmigrant parents, citizen children with an immigrant parent
had a greater increase in the probability of having no unmet
health need (17.2 percentage point increase vs 6.5 percentage point increase, P < .01), as did immigrant children
(32.7 percentage point increase vs 6.5 percentage point increase, P < .01) (Fig. 2C).

DISCUSSION
All low-income children, regardless of family immigration status, experienced gains in health insurance coverage
and access to care from 2003 to 20112012 in this analysis
of a large, nationally representative data set. Additionally,
we observed that disparities lessened between citizen children with immigrant parents and citizen children with
nonimmigrant parents in having any health insurance
coverage, having a personal doctor or nurse, and having
no unmet health need. Although disparities lessened over
time between immigrant children and citizen children

JARLENSKI ET AL

ACADEMIC PEDIATRICS

Figure 2. Predicted probabilities of access to care among low-income children by family immigration status, 2003, 2007, and 20112012. (A)
Personal doctor or nurse. (B) Any preventive care use. (C) No unmet health need. Low-income is defined as family income <200% of the
federal poverty level. Predicted probabilities are from multivariable logistic regression controlling for childrens age, sex, race, ethnicity, health
status, family structure, family language, parents employment and education, and state of residence.

with nonimmigrant parents in having a personal doctor or

nurse and having no unmet health needs, large and significant disparities still exist. In 20112012, an estimated
34.5% of low-income immigrant children lacked health insurance coverage and an estimated 33.1% of low-income
immigrant children lacked a personal doctor or nurse.
This is the first study, to our knowledge, to examine time
trends in disparities among low-income children by family
immigration status in health insurance coverage and access
to care, and to distinguish between citizen children with an
immigrant parent and immigrant children. Our findings of

lessening disparities on some insurance coverage measures

may reflect success of incremental policy efforts, such as
state options under the CHIP reauthorization to extend
coverage to low-income immigrant children who have
been in the United States legally but for fewer than 5
years.29 Such incremental expansions of health insurance
coverage could also lead to decreases in disparities in access to care. Additionally, the increases in health insurance
coverage we observed may be due to efforts to reach
vulnerable populations. Coverage has reached high levels
($90%) among low-income children with nonimmigrant

ACADEMIC PEDIATRICS

parents,30 which might spur an increased focus on

conducting outreach and enrollment efforts among lowincome children with immigrant parents. The accompanying lessening of immigration-related disparities over
time in some measures of access to care are promising
and could suggest that recently insured children are
seeking care. It is surprising that immigrant children experienced a large improvement in having no unmet health
need, despite a relatively smaller increase in health insurance coverage. This might be explained by increased use
of safety net providers or school-based health services,
and merits future research.
At the same time, however, our results highlight the limitations of current federal health insurance policies that
exclude most low-income immigrants from Medicaid or
subsidized coverage.31 In particular, our analyses found
that low-income immigrant children consistently fared
worse on health insurance coverage and access to care.
Low-income immigrant families may face cultural barriers
to obtaining health insurance coverage for children, such as
a lack of family experience with health insurance programs32 or distrust of the health care system.33 Additionally, immigrant families often have misperceptions about
their childrens eligibility for Medicaid/CHIP coverage.34
Disparities in insurance and access to care are particularly
problematic because they imply disparities in health outcomes.3
There is increasing recognition from the research and
policy communities that targeted policy efforts are needed
to reach low-income immigrant populations. Such efforts
include conducting multi-lingual enrollment counseling
or partnering with trusted community groups to reach
eligible but uninsured low-income immigrant populations.35 Additionally, states might explore ways to fully
include low-income immigrants in eligibility for public
coverage. For example, a legislative package in the California Legislature would extend California Medicaid
coverage to all low-income children regardless of immigration status, as well as enacting additional protections for
immigrant populations.36
In addition to policy measures expanding insurance
coverage, effective interventions should be implemented
to ensure that low-income immigrant families are actually
accessing coverage and engaging with the health care
system. For example, recent research documented an
improvement in childrens health insurance status though
parent mentors who shared their experience with the
health insurance system with other parents to enroll
eligible children.37 Engaging parents with shared experiences might be a particularly important facilitator of
outreach and enrollment in coverage for low-income
immigrant families under the ACA. Ongoing research is
needed to evaluate such community-level interventions
on a broader scale, and across multiple states. As the
ACA is implemented, it will be important to both document whether certain vulnerable populations are being
left behind and to continue to identify policies and practices to achieve universal health insurance coverage and
access to care for low-income families.

INSURANCE COVERAGE AND IMMIGRATION STATUS

LIMITATIONS
Our study should be interpreted in light of several limitations. First, the NSCH is a population-based telephone survey and therefore subject to nonresponse bias. However,
the analytic data set incorporates survey weights to reduce
this nonresponse bias.20,21 Second, nonresponse could be
greater among immigrant families due to language and
cultural barriers. Additionally, surveys were conducted via
landline telephone numbers only in 2003 and 2007 and a
cellular phone component was added in 20112012.
Nonresponse could conceivably be greater in immigrant
populations who may not have landlines. If such
differential nonresponse bias occurred and was correlated
with worse insurance and access to care, our results might
overestimate the reduction in immigration-related disparities. Also, it is unknown whether nonresponse bias changed
by family immigration status over time. Nonresponse due
specifically to language barriers is minimized as the NSCH
is professionally translated into 5 different languages spoken
by immigrant populations in the United States.20,21,23 Third,
all measures are based on self-report of a parent or guardian
on behalf of a child, meaning that some measurement error is
inevitable. It is unknown whether this error might systematically differ by immigration status. Fourth, we are unable to
distinguish childrens or their parents legal status in the data,
so we are unable to make any conclusions about children or
parents who are undocumented immigrants. Finally, we are
unable to determine whether parents had access to
employer-sponsored health insurance, which could affect
health insurance coverage and access to care for children.
CONCLUSIONS
Although all children in low-income families experienced gains in health insurance coverage and access to
care from 2003 to 20112012, large disparities related to
family immigration status persisted. Given that the ACA
excludes many low-income immigrants from Medicaid/
CHIP or subsidized insurance, policy efforts are needed
to ensure that children in low-income immigrant families
are able to access health insurance and health care.
SUPPLEMENTARY DATA
Supplementary data related to this article can be found at
10.1016/j.acap.2015.07.008.

REFERENCES
1. Harringon M, Smith K, Trenholm C, et al. CHIPRA mandated evaluation of the Childrens Health Insurance Program: final findings.
2014. Report submitted to the Office of the Assistant Secretary for
Planning and Evaluation. Available at: http://medicaid.gov/chip/
downloads/chip_report_congress-2014.pdf.
Accessed
August
8, 2015.
2. Selden TM, Hudson JL. Access to care and utilization among children: estimating the effects of public and private coverage. Med
Care. 2006;44(5 suppl):I19I26.
3. Howell EM, Kenney GM. The impact of the Medicaid/CHIP expansions on children: a synthesis of the evidence. Med Care Res Rev.
2012;69:372396.

JARLENSKI ET AL

4. Cohodes S, Grossman D, Kleiner S, et al. The effect of child health

insurance access on schooling: evidence from public insurance expansions. NBER Working Paper 20178. Cambridge, Mass: National
Bureau of Economic Research; 2014.
5. Howell E, Decker S, Hogan S, et al. Declining child mortality and
continuing racial disparities in the era of the Medicaid and SCHIP
insurance coverage expansions. Am J Public Health. 2010;100:
25002506.
6. Seiber EE. Covering the remaining uninsured children: almost half of
uninsured children live in immigrant families. Med Care. 2014;52:
202207.
7. Derose KP, Escarce JJ, Lurie N. Immigrants and health care: sources
of vulnerability. Health Aff (Millwood). 2007;26:12581268.
8. Lasser KE, Himmelstein DU, Woolhandler S. Access to care, health
status, and health disparities in the United States and Canada: results
of a cross-national population-based survey. Am J Public Health.
2006;96:13001307.
9. DeVoe JE, Marino M, Angier H, et al. Effect of expanding Medicaid
for parents on childrens health insurance coverage: lessons from the
oregon experiment. JAMA Pediatr. 2015;169:e143145.
10. Davidoff A, Dubay L, Kenney G, et al. The effect of parents insurance coverage on access to care for low-income children. Inquiry.
2003;40:254268.
11. Sommers BD. Stuck between health and immigration reformcare
for undocumented immigrants. N Engl J Med. 2013;369:593595.
12. Sommers BD, Parmet WE. Health care for immigrantsimplications
of Obamas executive action. N Engl J Med. 2015;372:11871189.
13. Wallace S, Torres JM, Nobari TZ, et al. Undocumented and uninsured:
barriers to affordable care for immigrant populations. Available at:
http://www.commonwealthfund.org/w/media/Files/Publications/Fund
%20Report/2013/Aug/1699_Wallace_undocumented_uninsured_barri
ers_immigrants_v2.pdfndocumented; 2013. Accessed April 9, 2015.
14. Heberlein M, Broos T, Alker J, et al. Getting Into Gear for 2014: Findings From a 50-State Survey of Eligibility, Enrollment, Renewal, and
Cost-Sharing Policies in Medicaid and CHIP. Washington, DC: Kaiser
Commission on Medicaid and the Uninsured. Available at: https://
kaiserfamilyfoundation.files.wordpress.com/2013/05/8401.pdf; 2013.
Accessed August 8, 2015.
15. Kaiser Commission on Medicaid and the Uninsured. Key facts on
health coverage for low-income immigrants today and under the
Affordable Care Act. Available at: http://kff.org/disparities-policy/
fact-sheet/key-facts-on-health-coverage-for-low/; 2013. Accessed
October 1, 2014.
16. Karlamangla S, Terhune C. Healthcare quandary: many Latinos still
lack insurance but shun Obamacare for fear that signing up will get
relatives deported. Los Angeles Times, November 10, 2014.
17. Maternal and Child Health Bureau in collaboration with the National
Center for Health Statistics. 2003 National Survey of Childrens
Health. 2003 NSCH Stata indicator data set prepared by the Data
Resource Center for Child and Adolescent Health, Child and Adolescent Health Measurement Initiative; 2003.
18. Maternal and Child Health Bureau in collaboration with the National
Center for Health Statistics. 2011/12 National Survey of Childrens
Health. 2011/12 NSCH Stata indicator data set prepared by the
Data Resource Center for Child and Adolescent Health, Child and
Adolescent Health Measurement Initiative; 2012.
19. Maternal and Child Health Bureau in collaboration with the National
Center for Health Statistics. 2007 National Survey of Childrens
Health. 2007 NSCH Stata indicator data set prepared by the Data

ACADEMIC PEDIATRICS

20.

21.

22.

23.

24.

25.

26.

27.
28.
29.

30.

31.
32.

33.

34.

35.
36.

37.

Resource Center for Child and Adolescent Health, Child and Adolescent Health Measurement Initiative; 2007.
Blumberg SJ, Foster EB, Frasier AM, et al. Design and operation of
the National Survey of Childrens Health, 2007. Vital Health Stat 1.
2012;1149.
Blumberg SJ, Olson L, Frankel MR, et al. Design and operation of the
National Survey of Childrens Health, 2003. Vital Health Stat 1.
2005;1131.
Ryan C. Language use in the United States: 2011. American Community Survey Reports, 2011. Available at: https://www.census.gov/
prod/2013pubs/acs-22.pdf. Accessed May 20, 2015.
National Center for Health Statistics. Frequently asked questions:
20112012 National Survey of Childrens Health 2013; ftp://ftp.
cdc.gov/pub/Health_Statistics/NCHS/slaits/nsch_2011_2012/01_Fre
quently_asked_questions/NSCH_2011_2012_FAQs.pdf. Accessed
October 1, 2014.
Cohen Ross D, Cox L. Preserving Recent Progress on Health
Coverage of Children and Families. 2003. Available at: http://kff.
org/medicaid/report/preserving-recent-progress-for-health-coverageof/. Accessed August 19, 2015.
Cohen Ross D, Cox L, Marks C. Resuming the Path to Health
Coverage for Children and Parents. 2006. Available at:http://kff.
org/medicaid/poll-finding/resuming-the-path-to-health-coverage-for/.
Accessed August 19, 2015.
Heberlein M, Brooks T, Guyer J, et al. Holding Steady, Looking
Ahead: Annual Findings of a 50-State Survey of Eligibility Rules,
Enrollment and Renewal Proecdures, and Cost-Sharing Practices in
Medicaid and CHIP. Available at: http://kff.org/health-reform/
report/holding-steady-looking-ahead-annual-findings-of/; 2011.
Accessed August 19, 2015.
White IR, Royston P, Wood AM. Multiple imputation using chained
equations: issues and guidance for practice. Stat Med. 2011;30:377399.
Little RJA, Rubin DB. Statistical Analysis With Missing Data. 2nd ed.
Hoboken, NJ: Wiley; 2002.
Saloner B, Koyawala N, Kenney GM. Coverage for low-income
immigrant children increased 24.5 percent in states that expanded
CHIPRA eligibility. Health Aff (Millwood). 2014;33:832839.
Seiber EE. Which states enroll their Medicaid-eligible, citizen children with immigrant parents? Health Serv Res. 2013;48(2 pt 1):
519538.
Ku L. Improving health insurance and access to care for children in
immigrant families. Ambul Pediatr. 2007;7:412420.
BeLue R, Miranda PY, Elewonibi BR, et al. The association of generation status and health insurance among US children. Pediatrics.
2014;134:307314.
Rhodes SD, Mann L, Siman FM, et al. The impact of local immigration enforcement policies on the health of immigrant Hispanics/
Latinos in the United States. Am J Public Health. 2015;105:329337.
Kenney GM, Haley JM, Anderson N, et al. Children eligible for
Medicaid or CHIP: who remains uninsured, and why? Acad Pediatr.
2015;15(3 suppl):S36S43.
Doty MM, Blumenthal D, Collins SR. The Affordable Care Act and
health insurance for Latinos. JAMA. 2014;312:17351736.
California Legislative Information System. Senate Bill 4: health care
coverage: immigration status. Available at: https://leginfo.legislature.
ca.gov/faces/billNavClient.xhtml?bill_id201520160SB4;
2015.
Accessed July 10, 2015.
Flores G, Walker C, Lin H, et al. A successful program for training
parent mentors to provide assistance with obtaining health insurance
for uninsured children. Acad Pediatr. 2015;15:275281.