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Gilberto Granados, MD, MPH, Jyoti Puvvula, MD, MPH, Nancy Berman, PhD and Patrick T. Dowling, MD, MPH

Gilberto Granados and Jyoti Puvvula are with the Department of Family Medicine, and Nancy Berman is with the Department of Pediatrics, Harbor–UCLA Medical Center, Los Angeles, Calif. At the time of the study, Patrick T. Dowling was with the Department of Family Medicine, Harbor–UCLA Medical Center, Los Angeles, Calif.

Correspondence: Requests for reprints should be sent to Gilberto Granados, Department of Family Medicine, Harbor–UCLA Medical Center, 1403 W. Lomita Blvd, Harbor City, CA 90710 (e-mail: ggranado{at}ucla.edu).

	ABSTRACT

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Objectives. This study sought to assess the impact of child and parental birthplace on insurance status and access to health care among Latino children in the United States.

Methods. A cross-sectional, in-person survey of 376 random households with children aged 1 to 12 years was conducted in a predominantly Latino community. Children's insurance status and access to routine health care were compared among 3 child–parent groups: US born–US born (UU), US born–immigrant (UI), and immigrant–immigrant (II).

Results. Uninsured rates for the 3 groups of children were 10% (UU), 23% (UI), and 64% (II). Rates for lack of access to routine health care were 5% (UU), 12% (UI), and 32% (II).

Conclusion. Latino children of immigrant parents are more likely to lack insurance and access to routine health care than are Latino children of US-born parents.

	INTRODUCTION

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The Latino community is one of the fastest growing ethnic groups in the United States; it now constitutes 8% of the US population, and soon it will be the largest minority group.^1–3 Of 9 million Latino children nationally, 25% are not covered by health insurance.⁴ In California, Latino children aged 0 to 17 years are 3 times as likely as their White counterparts to be uninsured.⁵ They also are more likely to encounter deficiencies in access to care.⁶ During the past decade, immigration patterns throughout the United States have resulted in families whose members have differing legal status.⁷ Latino children frequently live in "mixed status" families composed of noncitizen parents and US-born citizen children. Roughly 85% of all immigrant families in the United States are of "mixed status." ⁸

Previous studies have shown that despite higher levels of potential eligibility, noncitizen families are less likely to have health insurance.⁶ In this study, we attempted to measure the impact of parental and child birthplace on insurance status and access to care among Latino children.

	METHODS

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For a 6-week period during the summer of 1997, we conducted household surveys to determine the health care access of children in the community of Wilmington, a poor, urban, predominantly Latino, working-class community within the city of Los Angeles. Using random cluster sampling, we surveyed a total of 376 eligible households to represent the target population, based on adjusted 1990 census data. Households were considered eligible if at least 1 child in the home was aged 1 to 12 years. Trained medical students interviewed the primary caregiver for a randomly chosen eligible child in the caregiver's preferred language (English or Spanish). The overall response rate was 66%; we assume that nonresponders are similar, if not identical, to those who were difficult to contact.⁹

We divided the children into 3 categories on the basis of their own and their parents' immigration status. The first group consisted of US-born children with US-born parents (UU); the second group consisted of US-born children with immigrant primary caregiver (UI)—the "mixed status" group; the third group consisted of immigrant children with immigrant parents (II).

We compared the 3 groups with respect to differences in health insurance status and access to care. A child was considered insured if the child was enrolled in some form of public or private health insurance at the time of the interview (children enrolled in emergency Medicaid only were excluded). Access to health care was defined as positive if a child had a usual source of care for routine well-child examinations.

We conducted ² tests to look for differences in parental sociodemographic factors among the 3 groups. We also looked at the impact of the parents' and child's immigration status on access to health care and the insurance status of the child. We used odds ratios to determine the most important factors in whether a child had access to care.

	RESULTS

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Parental Sociodemographic Variables and Parent–Child Birthplace
In the UU group, 97% of primary caregivers were English speaking, and 36% had more than a 12th-grade education. In contrast, the parents in the UI and II groups were predominantly Spanish speaking (UI = 55%, II = 69%), and only 14% of the parents in these groups had more than a 12th-grade education. The UI and II groups had a much higher proportion of 2-parent households: 85% for the UI group and 71% for the II group, compared with only 46% for the UU group. There were no significant differences in the employment patterns of the 3 groups. In all 3 groups, 80% of primary caregivers had full-time or part-time employment.

Child's Insurance Status and Access to Care in Relation to Parent–Child Birthplace
There were significant differences among the 3 groups with regard to the child's insurance status and access to care (Table 1). In the UU group, 11% of children lacked insurance, compared with 23% in the UI group and 64% in the II group. Thus, the rate of lack of insurance among children in the UI group was double that among children in the UU group; children in the II group were 6 times as likely to lack insurance as children in the UU group. Whereas 5% of children in the UU group did not have a regular source of care, the rate was almost 2.5 times as high for children in the UI group (12%) and more than 6 times as high for children in the II group (32%).

	DISCUSSION

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The lower rate of health insurance enrollment found among immigrant parents may be partly attributable to the fact that immigrant parents are more likely than nonimmigrant parents to face noneligibility barriers to enrolling their children. The lower education level of many Latino immigrant parents may place them in low-wage jobs that seldom offer health benefits. This factor may explain a counterintuitive trend we found in our study: Children have poorer access to health insurance and health care when both parents are employed than when only 1 parent is employed.

Given that health insurance is the most important predictor of access to health care, barriers such as birthplace can be overcome if health insurance expansion programs view children in the context of their families and not only as individuals.

	Acknowledgments

 
We would like to thank the California Area Health Education Center for its support.

	Footnotes

 
G. Granados, J. Puvvula, and P. T. Dowling planned the study, developed the measuring instrument, oversaw the data collection, analyzed the data, and wrote and revised the manuscript. N. Berman assisted with the study design, analyzed the data, and significantly contributed to the writing and revising of the manuscript.

Peer Reviewed

Accepted for publication February 23, 2001.

	References

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1. The Hispanic Population in the United States: March 1988. Washington, DC: US Bureau of the Census; 1998. Current Population Report Series p-20, No. 438.

2. Council on Scientific Affairs. Hispanic health in the United States. JAMA.1991;265:248–252.[Abstract/Free Full Text]

3. Mendoza FS. The health of Latino children in the United States. Future Child. 1994;4:43–72.[Medline]

4. Flores G, Vega L. Barriers to health care access for Latino children: a review. Fam Med. 1998;30:196–205.[Medline]

5. Brown ER, Wallace SP, Pourat N, Yu H. New estimates find 400,000 children eligible for healthy families program. Policy brief. Los Angeles, Calif: UCLA Center for Health Policy Research; October 1998.

6. Hubble FA, Waitzkin H, Mishra S, Chavez LR. Access to medical care for documented and undocumented Latinos in a southern California county. West J Med. 1991;154:414–417.[Medline]

7. Healthy Families and Medi-Cal for Children Enrollment Issues: Joint Oversight Hearing Before California Legislature Assembly Committees on Health and Insurance and Senate Committee on Health and Human Services Insurance (October 21, 1998) (statement of Michael Fix, Urban Institute).

8. Fix M, Zimmerman W. All Under One Roof: Mixed Status Families in an Era of Reform. Washington, DC: Urban Institute; 1999.

9. Potthoff RF, Manton KG, Woodbury MA. Correcting for nonavailability bias in surveys by weighting based on number of callbacks. J Am Stat Assoc.1993;88:1197–1207.

10. Halfon N, Wood DL, Valdez RB. Medicaid enrollment and health services access by Latino children in inner-city Los Angeles. JAMA.1997;227:636–641.

11. Zimmerman W, Fix M. Declining Immigrant Applications for Medi-Cal and Welfare Benefits in Los Angeles County. Washington, DC: Urban Institute; 1998.

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