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Journal Issue: Immigrant Children Volume 21 Number 1 Spring 2011

The Physical and Psychological Well-Being of Immigrant Children
Krista M. Perreira India J. Ornelas

Strategies to Promote Health

To better promote the health of immigrant children, health researchers and reformers must improve their understanding of these children's unique experiences, reduce barriers to medical insurance for immigrant populations, and improve access to care and the capacity of providers to work with multilingual and multicultural populations.

Understanding the Unique Experiences of Immigrant Children
In the past decade, scholars have learned much about the immigrant experience and its influence on children's health. Still, critical knowledge gaps remain. As research progresses, scholars need to develop country-of-origin-specific, longitudinal, and binational data—data collected both in immigrants' countries of origin and in the United States—on immigrant parents and their children.

In the absence of data specific to country of origin, researchers classify immigrants into large pan-ethnic groups such as Asian and Hispanic. These groupings obscure substantial socioeconomic, cultural, and political differences that exist between the immigrant children from different countries of origin within the same world region and can lead to erroneous conclusions regarding the relationship between migration and health.

To better understand the developmental consequences of migration, national longitudinal data on the children of immigrants are also sorely needed. Most data are gathered in specific geographic regions of the United States, are cross-sectional, and do not contain detailed information on both immigrant parents and their children. Consequently, researchers know little about how migration and acculturation experiences shape the development of children over time and across family generations. Moreover, the data do not allow researchers to identify how the context of settlement into particular areas of the United States shapes the health and development of immigrant children. States and communities vary widely in their cost of living, employment opportunities, racial composition, and infrastructure for serving immigrant families—all factors that can influence the health and development of children of immigrants.

Finally, comparable binational data are needed on the health of children and their parents. We cannot fully understand how migration and acculturation influence health without knowing more about the health of the populations from which immigrant children come and the context of their migration to the United States. Binational data will enable evaluations of how health, beliefs and attitudes about health, and health care use patterns in primary sending regions differ from those of the children of immigrants living in the United States. These data are critical for understanding health selection effects and designing effective prevention and treatment programs for an increasingly transnational population.

Reducing Barriers to Medical Insurance
Once immigrant parents and their children are in the United States, their health depends critically on their access to care—a factor influenced substantially by insurance coverage. Four-fifths of the nation's 46 million uninsured are U.S. citizens. The Congressional Budget Office estimates that health care reform will, by 2019, reduce the number of uninsured to 23 million, one-third of whom will be nonelderly, unauthorized immigrants.81 Thus, health reform has important implications for access to medical care for immigrants and their children.

With the passage of the 2009 Children's Health Insurance Program Reauthorization Act, states now have the option of providing legal immigrant children and pregnant women access to federally funded health insurance through CHIP regardless of how long they have lived in the United States. The policy for adults remains more restrictive. The health insurance reform bill passed in 2010, formally known as the Patient Protection and Affordable Care Act, bars legal immigrants from receiving Medicaid during their first five years in the country. However, immigrants who earn up to 400 percent of the federal poverty level and have no access to employer-provided coverage may purchase federally subsidized insurance through state exchanges. The new law makes unauthorized immigrant children and adults ineligible for Medicaid coverage and insurance options available through the exchanges. Medicaid will continue to cover only emergency care services for uninsured, unauthorized immigrants.

Despite the continued restrictions on adult immigrants' access to Medicaid, expansions in the availability of employer-provided coverage and in the eligibility of Medicaid will likely improve access to care. Employers with more than fifty employees will now be required to offer coverage to their workers, including immigrants and, potentially, their children. Additionally, single adults without children and with incomes up to 133 percent of the federal poverty line will now be eligible for Medicaid. Previous Medicaid eligibility requirements substantially limited coverage for adults without children. Finally, insurers will be required to cover children with preexisting medical conditions, and children can stay on their parents' insurance until age twenty-six. These are substantial improvements that will benefit millions of Americans, including immigrants.

Improving Access to Medical Services
On average, immigrants use less medical care, including less emergency room care, and have lower average medical expenditures than U.S. citizens. Health reform will begin to improve immigrants' access to care by relaxing restrictions on eligibility for public insurance and by improving affordability for individuals purchasing insurance through the nongroup market. However, additional steps will be needed to further promote access to care for the children of immigrants.

First, health care providers need to be sensitive to immigrants' cultures and their preferences for particular modes of delivery (that is, times, locations, and language). The availability of culturally competent care that respects patients' religious, family, and cultural values can improve the doctor-patient relationship and make it easier for immigrant parents to seek care. For example, because some immigrant populations rely on family, social networks, and complementary and alternative medicine for information about health and medical services, medical care providers can improve access to care by establishing lay health adviser programs designed to educate natural leaders in immigrant communities and build liaisons with these communities. Because immigrants can have limited access to a car and may not have a driver's license, providers can improve access by locating clinics within immigrant communities or near public transportation. And because immigrant parents may not have sick leave or flexible work schedules, clinic hours that extend beyond the standard 9–5 schedule can be essential to improving access. These and other possible strategies go beyond addressing the financial and linguistic barriers to medical care for immigrants.

Second, policy makers need to reduce additional structural barriers limiting the ability of immigrant children and their parents to access care. For example, federal civil rights policies require publicly funded providers to ensure that non-English speakers are able to access all their services, including applications and telephone appointment services. However, many states have not strictly enforced these requirements. Although Medicaid and CHIP allow states to include foreign-language interpreter services as an option, only twelve states currently do so. To encourage states to expand their translation and interpretation services, the health reform law has increased federal Medicaid and CHIP matching funds for these services.

In addition, policy makers can also remove state and local ordinances requiring a patient to show proof of citizenship before receiving care provided by local public health departments and community clinics. These policies reduce access to care not only for immigrants but also for many citizens who lack proper forms of documentation such as birth certificates and passports.

Finally, states will need to invest in outreach to increase enrollment in health insurance programs and use of existing services. Studies have shown that outreach efforts can ensure that immigrants take advantage of available services and use them efficiently.82 Without outreach efforts, immigrants may fail to take advantage of expansions in health insurance coverage and may remain unaware of improvements in other aspects of care (such as the availability of translators) available to them.