C P R C B r i e fC A L I F O R N I A P R O G R A M O N A C C E S S T O C A R E

CPR

CR E S E A R C H S E R V I N G C A L I F O R N I A

CALIFORNIA POLICY RESEARCH CENTER

U N I V E R S I T Y O F C A L I F O R N I A

Public Forums Sponsored by the Board on Children,Youth, and Families of the National Research Council/Institute of Medicine and the UCLA Center for HealthPolicy Research December 10–11, 1998, Sacramentoand Los Angeles

Introduction

Although one in three children in immigrant fami-lies in the United States lives in California, fewstudies have documented the health of this popu-lation.This lack of data has been of particular con-cern since passage of the 1996 federal welfarereform legislation, which reduced access to healthservices for many immigrants and their children.Even where these children are entitled to Medicaidor the new Children’s Health Insurance Program(CHIP), perceived threats based on immigration orcitizenship status have created access barriers, en-dangering the health and well-being of both immi-grant and U.S.-born children in immigrantfamilies.

On December 10–11, 1998 the Board on Chil-dren,Youth, and Families of the National ResearchCouncil/Institute of Medicine and the UCLACenter for Health Policy Research held two forumsentitled “Children in Immigrant Families: Issues for

California’s Future.”At meetings in Sacramento andLos Angeles more than 200 policy makers, advo-cates, and researchers discussed policies for healthaccess for immigrant children. The NationalResearch Council/Institute of Medicine studyFrom Generation to Generation: Health and Well-Beingof Children in Immigrant Families served as a launch-ing point for discussions.

The study reviewed demographics and character-istics of first- and second-generation immigrantchildren, including their development, risk factors,and access to and utilization of health and socialservices.A key conclusion was that first-generationimmigrant children are as healthy as, and in manyways healthier than, children in U.S.-born families,but health status declines as they assimilate intoAmerican life.

Children in immigrant families are three times aslikely to be uninsured as children in U.S.-bornfamilies. Even when they are insured, they face lan-guage and cultural barriers that may prevent themfrom receiving quality health care. As many of thepresenters and other conference participants pointedout, welfare reforms barred new immigrant chil-dren from the Medicaid program,a crucial safety net,and excluded them from participation in CHIP,

which provides free or low-cost in-surance for uninsured children infamilies whose incomes are abovethe eligibility levels for Medicaid.

Children in Immigrant Families:Issues for California’s Future

Vol. 12 No. 5 August 2000

Published Jointly with the UCLACenter for Health Policy Research

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While many of the lost benefits have since beenlegally restored, particularly in California, severalspeakers noted that such policies have led to a sub-stantial reduction in applications by eligible immi-grants to public programs. For example, at the timeof the forums only 48,000 of an estimated 328,000eligible children had enrolled in Healthy Families,California’s CHIP program. (Editor’s note: as of June2000 the total number of subscribers was 293,000.)

Although enrollment has increased, many of theissues addressed in the study and the forum remainto be resolved. Many of the eligible unenrolledchildren are in immigrant families; half of the state’scitizen children eligible for Medi-Cal or HealthyFamilies have at least one noncitizen parent. Severalexplanations for the earlier low enrollment figureswere offered, including the complicated applicationprocess, the use of co-payments, and inadequateprogram publicity. However, a particular concernwas that families with mixed immigration statuseswere opting not to insure eligible children becauseof fear that doing so would jeopardize the immi-gration status of other family members.

The number of eligible but unenrolled childrenhighlights the negative effects of the public chargeissue. Conference participants related instances inwhich local jurisdictions posted signs that are in-timidating to immigrants, giving them the impres-sion that if their legal status is in question, they arenot welcome. Many noncitizen families fear thatenrolling even their citizen children in Medi-Cal,Healthy Families, or other means-tested programsmay be used against them when they try to renewtheir visas, return to the United States after travelingabroad, or apply for citizenship.

Recent policy changes have allayed some of thesefears, as reflected in increased enrollment in HealthyFamilies.The INS and the State Department ruledin May 1999 that noncitizens will not be classifiedas “public charges” if they or their children enroll inMedicaid or CHIP (except those who receivelong-term care under Medicaid). This policychange, if effectively communicated to parents,should help assure families that they do not have tofear these programs.

Conference participants lamented the fact thatconcern over basic access issues such as these isimpeding the work of learning more about themany non-access issues that contribute, for betteror worse, to the health status of children in im-migrant families.

Barriers to collecting data about the health of im-migrant children include lack of funding and thesmall sample size of immigrant subpopulationswithin health surveys. One speaker noted that his-tory suggests immigrants will be undercounted inthe 2000 U.S. Census, undermining its ability toprovide potentially useful information. Finally, re-search that includes questions about immigrationstatus may deter immigrants from participating,given evidence that many choose not to take partin programs for which they are entitled.

As noted, conference participants supported the re-port’s call for longitudinal studies, but also pointedto the need for more immediate data on the healthof immigrant children, so that practitioners andcommunity-based organizations can respond toemerging problems.

Research NeedsMany speakers gave specific recommendations re-garding future research priorities.They also notedthat more information on the comparative social,economic, and epidemiological profiles of the areasfrom which people immigrate to California wouldassist providers in enhancing the health of this pop-ulation.To that end, more data are also needed onaspects of healthy development unique to childrenin immigrant families. Concern over the report’sfinding that immigrants tend to be healthier uponarrival, but become less healthy as they assimilateinto American society, led to agreement that thecauses of this trend—as well as interventions de-signed to reverse it—should be investigated in fu-ture studies.

Research is also needed on the availability of inter-pretation services in the health care setting; on theefficacy of community health workers in com-pensating for the lack of culturally competentproviders; and on the role played by traditional

practices and remedies in health and healing.Theneed to identify measures of cultural competenceand its role in achieving positive outcomes was alsoidentified. One speaker discussed the shortage ofinformation on immigrants as health care con-sumers and recommended collecting data for pub-lic and private health care plans. The utilizationpatterns of various immigrant groups can be usedto inform and influence the types and marketing ofbenefit packages offered by health care plans.

Finally, speakers argued that this research should in-corporate major participation from the communitybeing studied with input at the design, implemen-tation, analysis, and dissemination phases.

Conference participants also discussed how best tomake the case to policy makers that a commitmentto the health of immigrant children is in everyone’sinterest. Speakers suggested that one of the most ef-fective strategies is to highlight changing demo-graphics and areas of “enlightened self-interest.”This includes the future social security tax base rep-resented by the current population of immigrantchildren and the potential consequences to the so-ciety as a whole if lack of access to quality healthcare prevents these children from becoming pro-ductive future members of the work force

Several speakers asserted that a dialogue involvingfederal, state, and local decision-makers is needed toaddress larger questions, such as the role of immi-grants in the development and future of this nation.Without a national consensus that immigrant fami-lies are an important part of the American fabricand deserve equal opportunities to succeed, any ef-forts to change public policy will merely be “tin-kering on the margins.”

Research Agenda

Presenters and symposium participants made rec-ommendations for research in the following fourareas:

Data Collection and Epidemiology

Conduct research on: the health status of immi-grant children;migrant agricultural workers, partic-ularly in relation to tuberculosis and HIV/AIDS;

and the epidemiological paradox in which immi-grant children’s health regresses to the U.S. mean.Conduct demographic studies on population pro-jections.

Establish databases on: the health of immigrant chil-dren nationwide and statewide; aspects of healthydevelopment unique to children in immigrant fam-ilies.Add data questions to existing state and federalhealth care surveys, and conduct longitudinal evalu-ations of existing programs.

Develop comparative social and epidemiologicprofiles of areas from which people emigrate, andimprove the collection and dissemination of data topolicy makers and the research community.

Behavioral and Social Science Research

© General:

Examine clustered risk-taking behaviors as wellas protective factors; and study the subpopula-tions that are in a continual migration patternbetween the U.S. and Mexico and CentralAmerica.

© Culture:

Provide cross-cultural training for those in themedical field; define cultural competence fromthe perspective of immigrant families; conductresearch on measures of cultural competence(utilization, patient satisfaction, quality of care,and health outcomes); identify important pro-tective factors; determine what contributes tothe dilution of these factors and how these pro-tective factors can be supported; identify immi-grants’ health assets and how they are threatenedby economic disparity in the U.S.; conduct re-search on effective interpretation/translation ser-vices and needed training; conduct research onlanguage access and cultural access issues;and ex-amine the role of alternative medicine and tradi-tional remedies in the health of immigrantfamilies.

© Education:

Conduct research on effective English as aSecond Language teaching methods.

© Media:

Conduct content analysis on the types of mediamessages young people are receiving; and iden-tify effective ways to translate scientific findingsinto sound bites.

© Community Health Education:

Study the impact of both community healthworkers and outreach among recently immigrat-ing populations; and develop a strategic plan forspending tobacco settlement dollars and ensur-ing that these funds go only into health care.

© Utilization of Services and Policy:

Determine why families eligible for Medi-Calhave expressed a preference for the HealthyFamilies Program instead; identify the social in-terests that society has in keeping people healthy,and utilize enlightened self-interest and areas ofcommon interest for advocacy in the policyarena.

Determine how the political environment, in-cluding policies such as Propositions 209 and187, affects immigrants’ experience; developcommunity outreach to assure immigrant par-ents that utilization of benefits for their childrenwill have no adverse impact on their own im-migration status; and conduct research thatpushes the envelope on a multicultural healthagenda.

© Health Services:

Conduct research on why many counties are notusing their indigent care programs to serve ei-ther newly arrived or undocumented immi-grants; utilization of services and health statusindicators; providing dental care to the childrenof migrant agricultural workers; the mentalhealth problems of migrant agricultural workersand how to provide services.

Study the interactions between health care uti-lization and outcomes, particularly for youngpeople; and develop research that will identifymethods for measuring performance outcomes.

Quantify the cost of insuring vs. the cost of notinsuring immigrant families; collect information

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on immigrants as consumers of health care;identify the best and most cost-effective healthcare for immigrant populations; identify thehealth insurance benefits immigrants want, anddetermine what insurance products for themshould look like; and determine strategies formarketing health insurance products to immi-grant families.

Identify the types of health care decisions thatfamilies with mixed immigration status are mak-ing; and examine whether HMOs have a dimin-ished capability to send a patient to a bilingual/bicultural provider and whether and howHMOs affect health care delivery to immigrantpopulations.

The forums on which this Brief is based were supported bya grant from The California Wellness Foundation.Thispublication was funded by the CPAC Technical AssistanceProgram at the request of Assembly Member Gil Cedilloof Los Angeles. Principal editors were Dan Gordon andDelight Satter of the UCLA Center for Health PolicyResearch, and Maria Chacon of the California Programon Access to Care.

The edited proceedings (44 pp) are available at no cost toCalifornia state government offices and for $15 to others(payable in advance by a check made out to UC Regents).

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