Association for Public Policy Analysis & Management

Over 6 million U.S.-­born citizen children have at least one parent who is undocumented. Little is known about the effect of parental documentation status on access to health insurance, and due to data limitations previous work has only been conducted at the national level. We examine the relationship between parental documentation status and children’s uninsurance at the state level.

We use a multiple imputation method to predict noncitizen adults’ documentation status and, from this, estimate state-­level uninsurance rates for U.S.-­born citizen children based on their parents’ documentation status. Our measure of documentation status originates from the Survey of Income & Program Participation (SIPP). However, the SIPP is not meant to be state-representative and likely underreports the number of undocumented immigrants. We apply SIPP model predictions – which we adjust for underreporting – to the American Community Survey (ACS), a large survey designed to be representative at the state level. This model is discussed in detail in a previous article on adults included and excluded from the ACA (Fried et. al. 2014). Our nationally representative sample includes 1,306,455 U.S.-­born citizen children from a pooled 2013 and 2014 ACS  sample. We compare national and state-­level rates of uninsurance between three groups of children: 1) children with at least one parent who is undocumented, 2) children with at least one immigrant (e.g., born outside U.S.) but no undocumented parent, and 3) children with only U.S.-­born parents.

Nationally, 10.3% of U.S.­-born children with at least one undocumented parent are uninsured, compared to only 5.0% of children with only U.S.­-born parents (p<.001). Children’s uninsurance, overall, varies from a low of 1.3% in Massachusetts to a high of 10.4% in Nevada. However, U.S.-born children with at least one undocumented parent have an uninsurance rate of 10.5% or higher in a total of 14 states, with the highest rate observed in Utah where 25.3% of children with at least one undocumented parent lack coverage (compared to 6.8% of children with only U.S.-born parents, p<.001). In some states, such as Massachusetts, there is no difference by parental documentation status. However, in the majority (60%) of the 45 states for which we were able to produce reliable estimates, children with at least one undocumented parent are significantly more likely to be uninsured than children with only U.S.-born parents. Moreover, large disparities are observed even in states with traditionally low rates of children’s uninsurance.

We demonstrate substantial disparities in national and state-level insurance by parental documentation status, and reveal even greater disparities in many states than those observed at the national level. Overall uninsurance has decreased significantly in recent years, yet there is a large group of U.S.-born children still experiencing significant gaps in coverage.

This study provides strong evidence that in many states U.S.-born children in undocumented immigrant families face greater barriers to coverage than their counterparts. Policy changes that reduce barriers uniquely tied to parental documentation status – combined with targeted outreach – could help to further reduce children’s uninsurance overall, particularly in states where disparities are largest.