J Immigrant Minority Health (2010) 12:273–281
DOI 10.1007/s10903-008-9185-8
ORIGINAL PAPER
Health Insurance and Access to Care for Families with Young
Children in California, 2001–2005: Differences by Immigration
Status
Gregory D. Stevens Æ Carmen N. West-Wright Æ
Kai-Ya Tsai
Published online: 9 September 2008
Ó Springer Science+Business Media, LLC 2008
Abstract Objectives To examine differences and trends
in health insurance coverage and access to care for
California families by immigration status. Methods Cross-
sectional data on 37,236 families with young children
\18 years of age from the 2001, 2003 and 2005 California
Health Interview Survey are used to assess trends in health
insurance and access to care for children and their parents
by four immigration dyads: (1) both are Citizens; (2) child
is a legal resident/citizen, and parent is legal resident
(Documented); (3) child is a citizen, and parent is undoc-
umented (Mixed); and (4) both are Undocumented. Results
Before and after adjustment for covariates, only children in
Undocumented dyads were less likely than Citizen dyads to
have insurance (OR = 0.20, CI: 0.16–0.26) and all three
measures of access: physician visits (OR = 0.69, CI: 0.52–
0.91), dental visits (OR = 0.47, CI: 0.35–0.63), and a
regular source of care (OR = 0.51, CI: 0.37–0.69). Parents
in all non-Citizen dyads had poorer access than Citizen
dyads across all measures, with the exception of dental
visits and a regular source for parents in Documented
dyads. Children of all dyads except Citizens were more
likely to be insured in 2005 vs. 2001. The largest gain was
for undocumented dyad children with 2.77 times higher
odds (CI: 1.62–4.75) of being insured in 2005 vs. 2001. All
children dyads except Mixed were also more likely to have
a physician visit. For parents, there was only a decrease in
The study was approved by the USC Office for the Protection of
Research Subjects.
G. D. Stevens (&)
C. N. West-Wright
K.-Y. Tsai
Department of Family Medicine, Center for Community Health
Studies, University of Southern California Keck School of
Medicine, 1000 South Fremont Ave, Unit #80, Alhambra, CA
91803, USA
e-mail: gstevens@usc.edu
insurance coverage for Citizen dyads (OR = 0.79, CI:
0.67–0.93) and few changes in access. Conclusions While
there were relatively few disparities and some improve-
ments in insurance coverage and access for children in
California (except for undocumented children), concomi-
tant changes for parents were not observed. Without
attention to the family in health care reforms, disparities
may not fully resolve for children and may continue or
even increase for parents.
Keywords Children
Immigrant families

Immigration status
Uninsured
Medicaid
SCHIP

Primary care
Access to care
Introduction
Immigrant families have been a major focus of health care
reform debates in California and nationally. This focus is
reflected in recent policies to tighten documentation
requirements to obtain Medicaid coverage and bar the
expenditure of public funds on individuals that do not have
legal resident status or a valid visa (often referred to as the
undocumented) [1–3]. In 2007, the California legislature
considered at least three major bills that involved whether
and how health services are delivered to immigrant fami-
lies [4].
Immigration is a particularly salient issue for California.
The U.S. Census estimates that in 2005 more than one-
quarter (27.2%) of individuals in California were foreign-
born (versus 12.4% nationally) and that 57.0% were non-
citizens [5]. Latinos are the largest immigrant group in
California, accounting for 45% of all new legal immigrants
each year. More than three-quarters of all immigrants
originate from Mexico, and the remaining reflect smaller
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274
groups from the Philippines, China, and India, each
accounting for 5% of immigrants each year [6]. Estimates
of the undocumented suggest that 25% or more of non-
citizens reside in the U.S. illegally [7, 8].
Prior studies have shown that immigrant families have
poorer access to care [9–12]. Some of these barriers are
very closely tied to race/ethnicity (e.g., language spoken),
and their effects are reflected in the many studies of dis-
parities in access to care for African-American, Latino, and
Asian families [13–17]. Several studies have described
barriers to accessing care faced by immigrant Latino and
Asian families, including a lack of familiarity in applying
for and enrolling in public insurance for less acculturated
families, difficulties communicating with providers and
fear this leads to misdiagnosis or medical error, and long
waiting times at health care settings available in these
communities [18–26]. Among adults, fear of public charge
has been shown to have detectable impacts on health care
access for these groups [27–29].
Despite being a major focus of health care policy
debates in California, however, there is very little infor-
mation on the health care experiences of families (both
children and parents) who are legal residents, of mixed
immigration status, or undocumented. Other studies have
shown that children in legal resident and undocumented
immigrant families are less likely than citizens to have
health insurance coverage and obtain medical and dental
care [30, 31]. It remains unknown, however, how immi-
gration status affects patterns of care for parents and
children, particularly for families members of mixed status.
The purpose of this study was to examine differences in
health insurance coverage and access to care for families in
California based on family dyads of immigration status (i.e.,
both the immigration status of the child and parent). Such
dyads are important because the health care utilization of
children and their parents is interrelated and barriers to care
that are experienced by one (including those associated with
immigration status) may affect access to care for the other.
This study further examines the extent to which insurance
coverage and access have changed for these dyads from
2001 to 2005. We present the study findings for children as
well as for their parents to present a comprehensive picture
of health care access for families overall.
Methods
Study Design and Sampling
This study analyzes data on 37,226 families with children
under 18 years of age from the 2001 (n = 15,802), 2003
(n = 10,681) and 2005 (n = 10,753) California Health
Interview Survey (CHIS). The study was approved by the
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J Immigrant Minority Health (2010) 12:273–281
USC Office for the Protection of Research Subjects. The
CHIS is conducted by the UCLA Center for Health Policy
Research, the California Department of Health Services
and the Public Health Institute. Each of the three cross-
sectional iterations of CHIS was completed with randomly
selected households in all California counties.
In a household, one adult was randomly selected for
interview. If the household had a child age 0–11 years, the
most knowledgeable adult was asked to answer questions
for one child selected at random. If the household had a
child age 12–17 years, one was randomly selected to
complete their own interview. For this study, analyses are
completed for family units defined as the adult respondent
(nearly always a parent, and so referred to from hereon as
parent) and one child. For the 16% of families in CHIS
with data available for two children (e.g., one child age 0–
11 years and a child age 12–17 years), we chose to limit
the analysis to one randomly selected child for inclusion in
the family unit. This was done to avoid correlation bias of
including two children from the same family.
Telephone interviews were conducted in seven lan-
guages: English, Spanish, Chinese (Mandarin and
Cantonese), Vietnamese, Korean and Khmer (Cambodian).
When a respondent could not speak English, several steps
were taken. First, the caller asked if there was another
person in the household who spoke English. If not, and the
respondent was Spanish speaking, a Spanish-speaking
interviewer was provided immediately. If a non-Spanish
speaking respondent told the caller what language he/she
speaks (the majority of cases), an interviewer able to speak
that language was provided. If the caller could not deter-
mine a respondent’s language, an audio recording of the
call was used to assess language and he/she was called
back by an interviewer able to speak that language. If a
respondent spoke a language other than one of the seven
listed above, they were finalized as a non-response.
The overall response rates of the 2001, 2003 and 2005
CHIS are slightly lower each year, as with many state and
national surveys. Response rates include the screener
completion rate (2001 = 59.2%, 2003 = 55.9% and
2005 = 49.8%), and interview completion rates in each
year for adults (63.7%, 59.9%, 54.0%), children (87.6%,
81.4%, 75.2%) and adolescents (63.5%, 57.3%, 48.5%).
More about the design and sampling of CHIS is available
online (www.chis.ucla.edu) [25].
Measures
Immigration Status Dyads
Immigration dyads were created based on the immigration
status of the child and parent. The four more common
groupings were used: (1) Citizen—where both child and
J Immigrant Minority Health (2010) 12:273–281
parent are citizens, (2) Documented—where child is a citi-
zen or legal resident and parent is a legal resident, (3)
Mixed—where child is a citizen and parent is undocu-
mented, and 4) Undocumented—where both child and
parent are undocumented. Despite equal legal eligibility for
public insurance coverage, a distinction was made between
Citizen and Documented dyads because they were expected
to be different in other ways that were likely to influence
obtaining access to care. We excluded families for whom
immigration status data was not available (1.2%).
Health Insurance Coverage and Access to Health Care
Health insurance coverage was reported by the parent
respondent and was dichotomized for this study as any
insurance coverage (private, public, or other) versus unin-
sured. Three measures of access to health care were used: (1)
physician visit in the past year, (2) dental visit in the past
year and (3) having a regular source of care. Responses for
both physician and dental visits were dichotomized as any
visit versus none. A regular source of care was defined as a
‘‘health care source (you/your child) usually visits if sick or
if advice is needed about (your/his or her) health.’’ An
emergency department was excluded as a regular source.
Covariates
Covariates used in adjusted analyses include child and
parent age (in years), child and parent gender, family
poverty status (B200% of the Federal Poverty Level or
FPL versus [200% of the FPL, based on family size and
income criteria), parent education level (high school
graduate or less, versus some college or more), and geo-
graphic residence (urban or second city, suburban, and
small town or rural).
Analysis
Analyses were performed using survey procedures in
STATA v10. Survey procedures were used to account for
the complex sampling design of the CHIS and to weight
estimates to be representative of all families in California.
The unit of analysis for all our analyses is the family. The
family is made up of one child and one parent for whom
the immigration dyad is applied. So even though we
present physician visits in the past year for child and parent
separately, the analysis is based on the family dyad that
reflects the immigration status of both.
Bivariate Analyses
Table 1 presents the demographic profiles of the immi-
gration status groups using three years of data combined,
275
except in the presentation of sample size and population
frequencies by immigration group. Population proportions
with standard errors are presented; are differences in the
demographic measures across immigration groups are
assessed with Pearson chi-squared.
Table 2 presents differences in access to care both
across immigration status groups and across years. Within
a given year, differences in access across immigration
status groups were tested overall using Pearson chi-
squared. And within a given immigration group, differ-
ences in access across years (2001 vs. 2003 and 2001 vs.
2005) were tested with Pearson chi-squared. The analyses
are completed for children and parents in separate analyses.
Bonferroni correction was used for all analyses to account
for multiple comparisons.
Multivariable Analyses
Table 3 present the results of logistic regression analysis to
examine differences in access to care for each immigration
group compared to a reference group of Citizen after
adjustment for the study covariates. Odds ratios (OR) and
95% confidence intervals (CI) are presented. The analyses
are completed for children and parents in separate analyses.
Table 4 presents the results of logistic regression anal-
yses to examine changes from 2001 to 2005 (or 2003 for
dental visits) in access to care by immigration group after
adjustment for the study covariates. ORs and 95% CIs are
presented, using 2001 as the reference group. Analyses are
completed for children and parents in separate analyses.
Results
Bivariate Results
Table 1 shows that children in Mixed dyad families are
younger (5.4 years) and children in Undocumented dyads
are older (9.8 years) than those in Citizen or Documented
dyad families (8.5 and 8.3 years). Parents in Citizen and
Documented dyads were slightly older than parents in
Mixed or Undocumented dyads (39.2 and 38.2 years vs.
32.4 and 34.9 years). Latinos compose a majority of
Documented (62.1%), Mixed (86.3%) and Undocumented
(76.3%) dyads. At least half of Mixed and Undocumented
dyad families lived in poverty (60.3% and 59.1%) versus
just 33.2% of Documented and 12.0% of Citizen dyad
families. About half or more of Documented, Mixed and
Undocumented dyad parents had not graduated from high
school (48.0%, 66.2%, and 58.5% vs. 10.0% of Citizen
dyads). They were also much more likely not to speak any
English at home (38.6%, 56.4% and 63.0% vs. 5.9% of
Citizen dyads).
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Table 1 Family demographics

Demographics Population % (Column percent and standard error)
by immigration status (all years
combined, unless noted) Citizen Documented Mixed Undocumented

Family sample size (n)

2001 12,764 1,756 940 342
2003 8,526 1,184 677 294
2005 8,792 1,078 639 244
Total 30,082 4,018 2,256 880
Family population freq (%)
2001 73.4 (.006) 13.6 (.005) 8.8 (.004) 2.8 (.002)
2003 73.9 (.006) 12.9 (.005) 8.2 (.004) 3.9 (.003)
2005 75.5 (.006) 12.2 (.006) 8.1 (.004) 3.4 (.003)
Age in years (mean)
Child* 8.5 (.042) 8.3 (.119) 5.4 (.136) 9.8 (.222)
Parent* 39.2 (.080) 38.2 (.204) 32.4 (.216) 34.9 (.398)
Gender (female)
Child 48.7 (.004) 47.4 (.012) 48.6 (.016) 53.1 (.025)
Parent* 64.9 (.004) 63.3 (.012) 71.9 (.014) 64.2 (.023)
Race/ethnicity of family*
Asian 8.8 (.003) 20.0 (.009) 4.7 (.006) 11.8 (.015)
African-American 9.0 (.003) 1.2 (.003) 0.5 (.003) 0.4 (.003)
Latino/Hispanic 19.2 (.004) 62.1 (.011) 86.3 (.011) 76.3 (.021)
Other 2.8 (.002) 1.6 (.003) 1.9 (.004) 1.9 (.009)
White 51.6 (.004) 8.6 (.006) 2.8 (.004) 3.2 (.006)
Mixed 8.5 (.003) 6.6 (.007) 3.9 (.007) 6.4 (.014)
Family poverty status*
Less than 100% FPL 12.0 (.003) 33.2 (.012) 60.3 (.015) 59.1 (.025)
100–199% FPL 18.8 (.004) 35.4 (.012) 30.1 (.014) 28.4 (.024)
200–299% FPL 16.5 (.003) 11.9 (.008) 5.0 (.006) 3.1 (.006)
300 FPL or higher 52.7 (.004) 19.5 (.008) 4.7 (.005) 9.4 (.012)
Parent education level*
\High school 10.0 (.003) 48.0 (.012) 66.2 (.015) 58.5 (.025)
High school graduate 25.5 (.004) 20.0 (.009) 17.8 (.012) 17.5 (.019)
Some college 29.8 (.004) 13.4 (.008) 7.5 (.007) 9.4 (.015)
College graduate 34.7 (.004) 18.7 (.008) 8.5 (.009) 14.7 (.016)
Parent non-English language* 5.9 (.002) 38.6 (.012) 56.4 (.016) 63.0 (.025)
* P \ .001 for the overall Geographic region*
difference across immigration Urban/second city 62.2 (.004) 73.9 (.010) 81.7 (.011) 80.5 (.018)
status groups for a demographic Suburban 24.7 (.004) 16.0 (.009) 11.2 (.010) 13.6 (.016)
variable
Rural/small town 13.1 (.003) 10.1 (.006) 7.0 (.007) 6.0 (.009)
FPL = Federal Poverty Level

Table 2 shows first that Documented, Mixed, and
Undocumented dyads were less likely to report the access
measures each year than Citizen dyads. This held for
children and parents. One of the largest differences was in
insurance coverage among parents in 2005, where 89.4% of
Citizen dyad parents had insurance, compared to 76.3% of
Documented dyad parents, 49.8% of Mixed dyad parents,
and 44.1% of Undocumented dyad parents (all P \ .01).
Increases were found in insurance coverage rates across
years for Documented, Mixed, and Undocumented dyad
children, but not Citizen dyad children. Undocumented
dyad children experienced the largest gains in coverage
from 2001 to 2005 (51.9% to 68.8%, P \ .05). Among
parents, documented dyads had the largest gains in insur-
ance (76.3% vs. 70.5% P \ .05), physician visits (79.9%
vs. 74.2%, P \ .05) and having a regular source of care
(86.5% vs. 79.1%), but also experienced a decrease in
dental visits (65.2% in 2001 vs. 57.9% in 2003, P \ .01).

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J Immigrant Minority Health (2010) 12:273–281 277

92.1(.005)***§
Multivariate Results

87.8(.024)

91.5(.005)
86.5(.018)
84.8(.018)

69.6(.049)

64.3(.031)
67.4(.048)
Table 3 pools three years of CHIS data and shows even
2005
after adjustment for covariates that children in Undocu-
mented dyads were less likely to have insurance
(OR = 0.20, CI: 0.16–0.26), physician visits (OR = 0.69,
90.3(.005)
85.6(.015)
93.2(.014)
73.3(.035)

89.8(.005)
79.9(.017)
66.0(.027)
70.3(.039)
CI: 0.52–0.91), dental visits (OR = 0.47, CI: 0.35–0.63),
2003

and a regular source of care (OR = 0.51, CI: 0.37–0.69)

* P \ .05, ** P \ .01, ***P \ .001 for the difference between 2001 and 2003 in a given dependent variable (e.g., insurance) within an immigration status group
Regular source

P \ .001 for the difference between 2001 and 2005 in a given dependent variable (e.g., insurance) within an immigration status group
than Citizen dyads. Children in Documented dyads were

Note: All overall differences across immigration status groups within a given year were statistically significant at P \ .01 for all years and access measures
less likely those in Citizen dyads to be insured (OR = 0.70,
94.0(.003)
88.8(.012)
92.9(.012)
74.7(.030)

89.9(.004)
79.1(.015)
63.4(.024)
66.3(.034)
CI: 0.57–0.85) and to have a regular source (OR = 0.78,
2001

CI: 0.63–0.96). Parents in Documented, Mixed, and

Undocumented dyads had poorer access than Citizen par-
ents across all measures, with the exception of dental visits
57.9(.021) **
77.0(.007)**
68.5(.019)
58.0(.027)
53.1(.042)

73.1(.007)

40.0(0.26)
37.4(.041) and a regular source for parents in Documented dyads.
Table 4 shows that after adjustment for the study
2003

covariates, children of all dyads except Citizens were more

likely to be insured in 2005 vs. 2001. The largest gain was in
Dental visit

79.3(.006)
70.0(.017)
63.1(.026)
50.8(.038)

74.0(.006)
65.2(.017)
42.0(.024)
48.4(.038)

undocumented dyad children who had 2.77 times higher

odds of being insured in 2005 vs. 2001 (CI: 1.62–4.75).
2001

Children of all dyads except Mixed were also more likely to

have a physician visit. Both Citizen and Documented chil-
88.4(.006)**§

dren were less likely to have a regular source of care in 2005

89.6(.020)*

79.9(.018)
84.8(.018)

76.1(.045)

85.2(.006)

67.1(.029)
61.4(.050)
Table 2 Differences in insurance coverage and access to care by immigration status and year, unadjusted

vs. 2001. For parents, there was a decrease for Citizen dyads
in insurance coverage (OR = 0.79, CI: 0.67–0.93) and an
2005

increase in having a regular source of care (OR = 1.26, CI:

1.07–1.49). Documented and Undocumented dyad parents
87.2(.005)
84.2(.015)
92.4(.014)
74.0(.038)

85.0(.006)
73.3(.019)
68.3(.026)
68.2(.039)

also experienced a decrease in dental visits.

2003
Physician visit

Discussion
85.2(.005)
80.3(.014)
86.9(.017)
68.0(.033)

84.3(.005)
74.2(.016)
66.4(.024)
65.5(.035)

This study shows that parents and their young children

2001

experienced very different access to care between 2001–

2005 in California. Before adjustment for socio-demo-
89.8(.019)**
91.0(.015)*

graphic variables, nearly all non-Citizen dyad children

68.8(.050)*

89.4(.006)
76.3(.021)
96.1(.004)

49.8(.032)
44.1(.052)

were less likely than Citizen dyads to have insurance and

report accessing health care. After adjustment, however,
2005
Population % (standard error)

only those children in Undocumented dyads had poorer

insurance coverage and access to care than those in Citizen
95.8(.003)
88.4(.014)
91.3(.016)
64.7(.039)

90.1(.005)
67.5(.020)
51.1(.027)
47.4(.043)

dyads, suggesting that for children, unless the child is

2003

undocumented, there are few disparities in insurance and

access to care associated with family immigration status.
The situation is much different for the parents of these
95.1(.003)
84.5(.012)
83.5(.017)
51.9(.038)

90.9(.004)
70.5(.017)
54.6(.024)
46.6(.039)

children. Both before and after adjustment, parents in non-

Insured
2001

Citizen dyads almost universally reported poorer insurance

§

coverage and access to care than parents in Citizen dyads.

P \ .01,

This suggests that disparities observed for the parents by

Immigration status

immigration status are not explained by other factors such

Undocumented

Undocumented

as race/ethnicity, poverty status, or insurance coverage (for

Documented

Documented

P \ .01,

the access measures), and that immigration status poten-

Citizen

Citizen
Parent
Mixed

Mixed

tially poses a much larger barrier to accessing care for

Child

adults than for their children.



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Table 3 Insurance coverage

Immigration status Odds ratios with 95% confidence intervals
and access to care by
immigration status, adjusted Insured Physician visit Dental visit Regular source

Child
Note: The reference group for
Citizen (ref) – – – –
all analyses is the Citizen
Immigration status group. Odds Documented 0.70 0.87 0.90 0.78
ratios marked in bold were 0.57–0.85 0.73–1.02 0.78–1.03 0.63–0.96
statistically significant at Mixed 0.79 0.96 1.04 0.82
P \ .05 or greater. All analyses
were adjusted for family 0.61–1.01 0.75–1.23 0.87–1.25 0.61–1.09
poverty status, child and parent Undocumented 0.20 0.69 0.47 0.51
insurance status (except when 0.16–0.26 0.52–0.91 0.35–0.63 0.37–0.69
insurance is the dependent
Parent
measure), parent education,
parent employment status, Citizen (ref) – – – –
family geographic region. Documented 0.56 0.73 0.95 0.84
Analyses of children were 0.48–0.65 0.63–0.84 0.83–1.10 0.71–1.00
further adjusted for child age,
Mixed 0.33 0.51 0.54 0.53
gender, race/ethnicity, and
health status. Analyses of 0.28–0.40 0.42–0.62 0.45–0.65 0.43–0.66
parents were further adjusted for Undocumented 0.24 0.56 0.59 0.73
parent age, gender, race/ 0.19–0.31 0.44–0.72 0.45–0.76 0.55–0.97
ethnicity and health status

Table 4 Changes over time in

Immigration status Odds ratios with 95% confidence intervals
insurance coverage and access
to care, adjusted Insured Physician visit Dental visit Regular source
2005 vs. 2001 2005 vs. 2001 2003 vs. 2001 2005 vs. 2001

Child
Citizen 1.21 1.38 1.01 0.74
0.96–1.53 1.19–1.60 0.90–1.13 0.61–0.90
Documented 2.01 1.41 0.97 0.64
Note: The reference group for 1.36–2.96 1.00–1.99 0.76–1.25 0.43–0.96
all analyses is Year = 2001. Mixed 1.87 1.50 1.01 0.62
Odds ratios marked in bold were 1.14–3.09 0.87–2.58 0.72–1.42 0.33–1.16
statistically significant at
Undocumented 2.77 1.72 0.95 0.79
P \ .05 or greater. All analyses
were adjusted for family 1.62–4.75 0.97–3.06 0.60–1.52 0.42–1.49
poverty status, child and parent Parent
insurance status (except when Citizen 0.79 1.02 0.97 1.26
insurance is the dependent
measure), parent education, 0.67–0.93 0.90–1.16 0.88–1.07 1.07–1.49
parent employment status, Documented 1.29 1.31 0.75 1.35
family geographic region. 0.97–1.72 0.98–1.77 0.59–0.95 0.90–2.03
Analyses of children were also
Mixed 0.83 1.30 0.92 1.13
adjusted for child age, gender,
race/ethnicity, and health status. 0.59–1.15 0.93–1.83 0.69–1.24 0.79–1.61
Analyses of parents were also Undocumented 1.06 0.92 0.57 1.32
adjusted for parent age, gender, 0.62–1.80 0.55–1.55 0.36–0.92 0.76–2.30
race/ethnicity and health status

Children fared much better than their parents with
regard to changes in insurance and access between 2001
and 2005. Children of all dyads except Citizens had an
increase in insurance even after adjustment for other fac-
tors. The only change for parents was a decline in coverage
among Citizen dyads. While all dyads of children except
Mixed experienced gains in physician visits, no changes at
all in physician visits were observed for parents. These
changes over time for children are summarized visually in
Fig. 1.
Most gains in insurance for children were due to public
programs that filled gaps left by decreased employer-based
insurance (data not shown). Even undocumented children,
ineligible for full-scope Medi-Cal, were more likely to be
enrolled in public coverage in 2005 than 2001. This was
most likely through programs like the Child Health and

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Fig. 1 Child health insurance status and access to care by immigra-
tion status and year, unadjusted. Four graphs reflect the proportion
that had: a insurance, b a physician visit in the past year, c a dental
Disability Prevention (CHDP) program, which allocates
Medi-Cal funds to cover preventive visits only, or Emer-
gency Medi-Cal, designed to provide short-term coverage
for care delivered in emergency settings. While limited
coverage is not ideal, it remains a key source of financing
for undocumented families.
The gains in insurance coverage for children were
matched by gains in physician visits for most immigration
dyads. However, no gains (and some decreases) in having a
regular source of care were observed among the same
children. While the reason is not clear, this may have to do
with the transition of children towards public coverage.
Enrollees in public programs are more likely to report
receiving care at a health center, outpatient department, or
other non-office-based setting. Such settings may be less
likely to be identified by families as a regular source due to
a greater reliance upon team care. This may be discon-
certing, but evidence suggests that these settings are similar
to physician offices in quality of care [32, 33].
279
visit in the past year, and d a regular source of care. * P \ 0.05 or
better for each immigration status group compared to Citizen within a
given year
Perhaps, more disconcerting is that increases in insur-
ance and access during this period were not found among
parents. With few exceptions, parents of all dyads experi-
enced very few changes (and only one increase) in any of
the measures studied. It is apparent that parents have
mostly been left out of efforts to expand eligibility for
public insurance coverage. Not only has this limited gains
in access for parents, but this may also limit improvements
in access for their children due to the strong correlation of
access within families [34–36].
There are some bright spots for immigrant families in
California. Throughout the state, counties have developed
local privately and publicly funded health insurance prod-
ucts—known as Healthy Kids—specifically for children
ineligible for other coverage (i.e., the undocumented).
Healthy Kids was operational in nine counties by the end of
2005, and provided new coverage to about 60,000 children
[37]. As of July, 2008 Healthy Kids programs expanded to
smaller counties (n = 28 total) and currently insure to
123
280
about 80,000 children. Prior studies show that Healthy Kids
improves access to needed medical and dental care among
enrollees [38–40]. Because the programs lack sustainable
funding, however, several may close within the next few
years [41].
There are some limitations to this study. First, it is only
representative of families with children ages 18 years or
less, not families with older children. Second, the measures
of access do not exclude visits for emergency or hospital
services, and so do not only reflect primary care. Third,
CHIS asks families to self-identify their immigration sta-
tus; thus the estimate of families who are undocumented is
likely an undercount. Moreover, undocumented families
who elect to respond may be less fearful of being identified
for reasons including previous use of the health care system
or public services without reprisal, or greater acculturation.
Thus, the findings for this group may overstate the expe-
riences of undocumented families generally. Fourth, the
CHIS does not explicitly capture non-traditional health
care utilization, which may be a large market for Latino or
Asian immigrants; and some Latino families may also seek
services in Mexico [42–45].
In conclusion, with immigration and health care reform
top issues in state and national politics, it will be necessary
to make informed decisions regarding how immigrant
populations will be served within the health care system.
While there are relatively few disparities in health insurance
coverage and access for children in California, concomitant
improvements for parents have not been observed. Without
attention to the family, it stands to reason that disparities
may not fully resolve for children and that disparities may
continue or even increase for parents.
Acknowledgements Funding for the research in this article was
provided by the California Program on Access to Care, an applied
policy research program administered by the California Policy
Research Center in the University of California, Office of the Presi-
dent. The authors’ views and recommendations do not necessarily
represent those of CPAC or the Regents of the University of
California.
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