Uninsured children in immigrant families: Left behind by health care reform?

Background: The Patient Protection and Affordable Care Act of 2010 (ACA) excluded undocumented immigrants from either purchasing coverage in the Exchange or from enrolling in the new Medicaid expansion. These provisions affect children in immigrant families either directly through their own citizenship status or indirectly through their parent's citizenship status. Objectives: Determine the extent of the population of children (ages 0-18) who will be either directly or indirectly affected by the ACA's exclusions pertaining to immigration status. Methods: The 2009 California Health Interview Survey (CHIS) was used, as it contains detailed information on immigration status for both children and their parents. This cross-sectional, 42,000 household survey was administered in English, Spanish, Korean, Mandarin, Cantonese and Vietnamese. Bivariate analysis determined the scope of the population potentially affected by the exclusions; multivariate analysis determined the importance of immigration and citizenship status as a factor in likelihood of being uninsured. The study focuses on children and their parents (ages 19-64), who resided in California in 2009. The total sample is 11,000 children, with a weighted population of 10,558,000. Immigration status was determined as follows: 1) child and parents citizens, 2) child citizen, at least one parent noncitizen with a green card, 3) child citizen, at least on parent noncitizen without green card, 4) child is noncitizen. Results: Bivariate findings show that noncitizen children (538,000) have a proportion of being uninsured that is over three times that of citizen children with citizen parents (27.4% compared to 8%). Citizen children with noncitizen parents have rates of being uninsured that are comparable to citizen children with citizen parents (13.7% with a green card and 10.3% without a green card). Multivariate results are still to be determined. Conclusions: These findings highlight the sizeable populations of uninsured children that will either be directly or indirectly excluded from obtaining coverage through ACA expansions. Nearly 150,000 uninsured noncitizen children in California will be directly affected by the ACA's provisions that exclude them from accessing the health insurance expansions either through Medi-Cal or the Exchange. The exclusions target the most vulnerable population, as it has the highest rates of being uninsured of any citizenship status group. An additional 100,000 uninsured children have noncitizen parents who don't have a green card, who might be wary of enrolling their children in government-sponsored programs for which they themselves are ineligible.