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Noncitizen children from families with mixed immigration status in the U.S. were far more likely to be uninsured than their citizen siblings, and that lack of coverage led to delays in needed medical care, a recent study found.

Examining family data from 2008-2018 where at least one child held citizenship and another did not showed that 42% of noncitizen children were uninsured compared to 12% of those with citizenship, reported Leighton Ku, MD, PhD, of George Washington University School of Public Health in Washington, D.C., and Mariellen Jewers, PhD, of Open Avenues Foundation in Boston.

Unsurprisingly, due to legal restrictions, far fewer noncitizen children were publicly insured through the Children's Health Insurance Program (CHIP) or Medicaid (39% of noncitizens vs 73% of citizen siblings). Private insurance, for which citizenship status isn't relevant, was similar (19% vs 15%, respectively), according to the findings in the July issue of .

Noncitizen status "leads to lower insurance coverage, and lower access to care," Ku said at a Tuesday briefing hosted by Health Affairs, adding that more than twice as many noncitizen kids experienced treatment delays in necessary medical care (7% vs 3%).

"This was mostly due to insurance services," and the associated costs of care, Ku said during the briefing -- which was sponsored by the California Health Care Foundation, California Endowment, and Con Alma Health Foundation. He noted that after controlling for insurance status, difference in treatment delays disappeared.

A second analysis in the study found that more than two-thirds of these noncitizen children eventually became citizens by age 30 or older.

Legal restrictions and exclusions in eligibility for CHIP have been in place for decades -- with a tied to immigration status operating in 48 states, as of 2020. A 1996 federal law established a 5-year waiting period for legal noncitizens to be eligible for Medicaid or CHIP. Another federal law in 2009 gave states the option of waving the waiting period and providing coverage for legal immigrant children and pregnant women, but undocumented children continued to be excluded.

In their paper, Ku and Jewers explained that "eligibility restrictions that prevent noncitizen children from being publicly insured can contribute to their experiencing poorer health and higher medical costs in their adult lives."

Their study leveraged data from two sources: the National Center for Health Statistics' National Health Interview Survey (NHIS), from 2008-2018, and the Census Bureau's 2020 Current Population Survey (CPS). The NHIS data allowed the researchers to gather a sample of mixed-status families, while the census data was used in a separate analysis to determine the degree to which noncitizen children ultimately became citizens.

Overall, the study included 251,861 citizen children and 8,282 noncitizen children in the U.S., as well as 8,405 children belonging to 2,832 "unique mixed-status families."

Using the "family-level fixed effects model," researchers were able to control for variables such as parents' race, ethnicity, and country of origin, as well as parental employment and education, family income, and different states' Medicaid policies tied to the family's residence or the survey year. The model also controlled for harder to observe variables such as parents' feelings about insurance and healthcare use, the study noted. The analysis also controlled for age and gender, with noncitizen children tending to be older than citizen children.

"The net effect of having this fixed effects system, where we can control for all the characteristics within the families, [is] it provides really strong evidence of causality," Ku said.

While these models are "not as definitive as randomized experiments," the study noted, the fixed effects models offer "a strong basis for identifying Medicaid and CHIP eligibility restrictions against noncitizens as a cause of immigrant children's poor health insurance status and limited medical care access."

The researchers zeroed in on three primary outcomes:

• Insurance coverage at the time the survey was taken
• Whether or not parents had postponed medical care due to cost in the past year
• Health status of the child (using a 1-5 Likert scale, ranging from poor to excellent)

The researchers found no significant differences in health status. "This is simply because most of the children are in excellent health," Ku said. "So we don't see much of those differences."

In the second analysis using the Census Bureau's 2020 CPS data, the researchers retrospectively looked at adults who came to the U.S. as noncitizen children and found that 70% of these individuals became citizens by the time they were age 30 or older.

Ku said the common thread between the two analyses is the issue of equity.

"And the question is 'Why would we want to construct barriers that make children from the same families be treated differently?'" he said. "I don't see why as a policy the U.S. would want to do that."

When they can, as is clear from the experience of parents with private insurance, parents "tend to cover their children in the same way," regardless of citizenship status, Ku said.

Ku argued that current U.S. policy threatens children's health insurance status and jeopardizes their access to healthcare.

While the study did not point to differences in health status between citizen and noncitizen siblings, other studies have shown beneficial affects of children receiving Medicaid early in life, he noted.

"Our analyses of CPS data indicate that the majority of noncitizen children grow up to become U.S. citizens," Ku and Jewers wrote in their paper. "Excluding them from health insurance coverage inhibits their health care access and can ultimately impair their health, both during childhood and into their adult years."

For that reason, Ku argued that lawmakers should consider eliminating restrictions on Medicaid related to citizenship. He pointed out that under current law, all states have the option to scrap the 5-year waiting period and roughly half have done so. Many states could go even further, , he noted.

"We are harming future citizens if we deny coverage early in life," said Ku.

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