Child Development, September/October 2012, Volume 83, Number 5, Pages 14941500

Health and Medical Care among the Children of Immigrants

Kathleen M. Ziol-Guest

Ariel Kalil

Cornell University

University of Chicago

Using data spanning 19962009 from multiple panels of the Survey of Income and Program Participation, this
study investigates childrens (average age 8.5 years) physical health, dental visits, and doctor contact among
low-income children (n = 46,148) in immigrant versus native households. Immigrant households are further
distinguished by household citizenship and immigration status. The findings show that children residing in
households with non-naturalized citizen parents, particularly those with a nonpermanent resident parent,
experience worse health and less access to care even when controlling for important demographic, socioeconomic, and health insurance variables.

Although immigrants make up less than 13% of the

total population, children of immigrants make up
22% of all children and 30% of low-income children
in the United States (Capps, Fix, Ost, ReardonAnderson, & Passel, 2004). Research suggesting disparate access to resources and opportunities for
immigrant families raises concerns about the development of this significant segment of the child population. For instance, children of immigrants are
much less likely to have health insurance than
native children, even after controlling for key
demographic characteristics (Hernandez, 2004), and
the barriers immigrant families face in accessing
health care often extend beyond those created by
insurance coverage issues (Capps, 2001; Currie,
2000; Lessard & Ku, 2003).
Moreover, the care accessed by immigrants is
likely to be of lower quality than that experienced
by native families (Ku & Matani, 2001). The fact
that immigrant children are at increased risk for
lacking health insurance and a regular place for
medical care partly explains why they are substantially more likely than their peers to be in poor
health (Reardon-Anderson, Capps, & Fix, 2002)
despite better health outcomes at birth and during
infancy (Ventura, Martin, Curtin, Mathews, & Park,
The first author would like to thank the Robert Wood Johnson
Foundation Health and Society Scholars program at Harvard
University. Support to the second author was provided in part
by a Young Scholar Award from the Changing Faces of
Americas Children program at the Foundation for Child Development.
Correspondence concerning this article should be addressed to
Kathleen M. Ziol-Guest, Department of Policy Analysis and
Management, Cornell University, Martha Van Rensselaer Hall,
Ithaca, NY 14853. Electronic mail may be sent to kmz7@
cornell.edu.

2000). This is concerning because health is increasingly recognized as an important component of

development, with links to childrens cognitive
functioning and academic success (Crosnoe, 2006;
Currie, 2005) and adult health and productivity
(Case, Fertig, & Paxson, 2005; Case, Lubotsky, &
Paxson, 2002; Marmot & Wadsworth, 1997).
An outstanding task is to identify who among
the immigrant child population is most at risk for
poor health outcomes. Children whose parents
have more precarious immigration statuses may be
the most reluctant to take up public health programs and children in these families may be at the
greatest risk (Yoshikawa & Kalil, 2011). Lurie (2008)
finds substantial declines in insurance coverage
among citizen children of nonpermanent residents
(but not the citizen children of permanent residents) in the late 1990s despite childrens eligibility
for these programs. It is likely that a large share of
the nonpermanent residents is in fact undocumented. Ortega et al. (2007) found that undocumented Mexicans and Latinos in California had
significantly fewer physician visits compared to
U.S.-born Mexicans. Undocumented Mexicans were
also less likely to have a usual source of care and
were more likely to report negative health-care
experiences than U.S.-born Mexicans.
The purpose of the present study is to test the
hypothesis that childrens health and access to and
use of health-care services differs in families with
different immigrant statuses (Ortega et al., 2007).

 2012 The Authors

Child Development  2012 Society for Research in Child Development, Inc.
All rights reserved. 0009-3920/2012/8305-0005
DOI: 10.1111/j.1467-8624.2012.01795.x

Health and Medical Care Among Children

To do so we compare differences in childrens

health and access to care in nonpermanent resident
households to their counterparts whose parents are
permanent residents, naturalized citizens, or
natives.

Method
Sample
Data are drawn from the 1996, 2001, 2004, and
2008 panels of the Survey of Income and Program
Participation (SIPP). The SIPP, which is conducted
by the Census Bureau, is a nationally representative
sample of households whose (noninstitutionalized)
members are interviewed at 4-month intervals
(each interview is considered a survey wave). Each
survey wave, the core, collects information on
demographic characteristics, labor force and program participation, amounts and types of earned
and unearned income, and private health insurance
from each individual in the household over the age
of 15 (adult population). Other questions, collected
as part of the topical modules, produce in-depth
information on specific subjects and are asked less
frequently. This study uses data from both the core
and topical modules.
The sample for our study is limited to lowincome households (less than 200% of the poverty
threshold for the family size) where a child under
age 18 resides. Specifically, average income in the 4
months prior to each wave in which the outcome is
measured is used to ascertain whether a child is
low income. Households are categorized according
to the citizenship status of the resident parent(s).
We allow children to be added (born into) sample
families within SIPP panels and children may contribute multiple observations within panels if they
meet the income criteria for multiple waves. The
final analytic sample includes 46,148 children or
80,673 child-wave observations.
Dependent Variables
Childrens health. Mothers in households assessed
the health of each child under age 15 (those over
age 15 responded for themselves) in the household
as excellent, very good, good, fair, or poor.
Responses originally ranged from 1 to 5 with a
higher value indicating poorer health. Among the
analytic sample, .48% of children were reported to
be in poor health, 2.71% in fair, 17.12% in good,
30.87% in very good, and 48.81% in excellent health
(weighted). Following Currie and Stabile (2003),

1495

this variable is recoded to contrast those in very

good or excellent health to those in poor, fair, or
good health.
Childrens health care utilization. Mothers are also
asked the following questions: (a) During the past
12 months, how many visits did the child make to
a dentist? and (b) Not including contacts during
hospital stays during the past 12 months, how
many times did you or anyone else see or talk to a
medical doctor or other medical provider about the
childs health? Two dichotomous measures are
created that represent whether or not the child had
any contact with a dentist or any contact with a
physician.
Independent Variables
Citizenship. The immigrant status of the households in which children reside is determined via
parental reports in the Wave 2 Migration Topical
Module for each panel. The Migration module is
administered to household members who are 15
or older (information on nonresident parents is not
available); thus, unfortunately we cannot determine the citizenship status of the children themselves. Childrens households are classified in the
following way: (a) as a nonpermanent resident
household if either parent in the household is a
nonpermanent resident, (b) as a permanent resident household if no parent is a nonpermanent
resident and at least one is a permanent resident,
(c) as a naturalized citizen household if no nonnaturalized parents reside in the household and at
least one naturalized parent does, and (d) as a
native household if all parents in the household
are native citizens.
Control variables: Childrens characteristics. We
control for three child demographic characteristics
(age, gender, and race) and a measure of health
insurance status in the childrens health analyses.
Age is measured as a continuous variable measured
in years at the time of assessment. Gender is measured as a dichotomous variable (girl is omitted).
Race and ethnicity is measured as four mutually
exclusive variables: non-Hispanic White, nonHispanic Black, Hispanic, and non-Hispanic Other
(White is omitted). Finally, whether or not the child
was covered by public health insurance or private
health insurance at the time of assessment is controlled (private insurance coverage is omitted).
Control variables: Household characteristics. We
control for several demographic characteristics of
these households and the household reference person in all analyses. The reference person is the

1496

Ziol-Guest and Kalil

person in whose name the home is owned or

rented; for married couples it could be the husband
or wife. First, the age of the head of household
measured is entered as a continuous variable. Second, we control for the educational attainment of
the head with three dichotomous variables: not a
high school graduate, a high school graduate, and
more than high school (high school graduate is
omitted). Heads employment is measured with
three dichotomous variables representing his or her
work status in the month during which the outcome is measured. Heads are classified as being (a)
out of the labor force (i.e., not working and no time
on layoff or looking for work), (b) in the labor force
with no periods of unemployment in that month,
or (c) in the labor force with some periods of unemployment in that month. The heads marital
status captured with four mutually exclusive
dichotomous
variables:
married,
widowed,
divorced or separated, and never married (omitted). Finally, the head of households report of anyone in the household receipt of food stamps or cash
welfare in the 4 months prior to the health outcomes is included (no receipt of food stamps and
no receipt of cash assistance omitted).
Household composition is assessed with two different variables. The first measure is the total number of children under the age of 18 residing in the
household. The second measure is the total number
of adults residing in the household, which can
include own children who are older than 18. We
also control for home ownership (coded 1 if yes, 0
otherwise) and we control for the log of monthly
household income averaged over the four months
prior to the interview (in $2005). We additionally
create a measure of self-reported health for the parents using the mother or the father, and averaging
these values if both are available. This is a continuous measure, where higher values reflect worse
self-reported health. Finally, all analyses include
fixed effects representing the year of the SIPP
panel.

Results
Table 1 presents the weighted means and standard
deviations of all variables in the analysis by parental citizenship status. On average, children in these
families are between 7 and 9 years of age with
equal numbers of boys and girls. Native children
are most likely to be White and the three immigrant
groups are most likely to be Hispanic (with large
shares of permanent and nonpermanent residents

represented in this category). The majority of these

low-income children are covered by some health
insurance, but being uninsured is much more likely
among the non-naturalized citizen households
(both permanent and nonpermanent residents). On
average, household heads have no more than a
high school degree, are employed, are married, and
do not receive government assistance. The average
monthly income for these families is between
$1,950 and $2,200 (in $2005).
Childrens Health
Table 1 also presents the prevalence of childrens
very good or excellent health, dental visits, and
doctor visits. Eighty percent of all of the lowincome children in the sample are rated in very
good or excellent health by their mothers, 49% have
had a dentist visit, and 60% have had a doctor visit
(data not shown). These figures vary by immigrant
status: Children in non-naturalized citizen households (both permanent and nonpermanent residents) are less likely (78% and 76%, respectively)
than children in both native (p < .001) and naturalized citizen (p < .001) households to be in very
good or excellent health.
Just over half of children residing in native
households went to the dentist at least once in the
previous 12 months, compared to half (50%) of naturalized citizens, but only 41% and 32% of children
in permanent and nonpermanent resident households, respectively. In all but the nonpermanent
resident household group the majority of children
visited the doctor in the previous 12 months.
Regression Analyses
One logistic regression model will be estimated
for each of the health outcomes. In all analyses, we
pool all observations across all years. Specifically,
we estimate the following equation:
h dy a1 a2 Naturala3 Perma4 Nonpermbj X 1
where h is the childrens health outcome; d denotes
a panel year fixed effect; Natural equals 1 if the
child resides in a household with a naturalized parent (and not a permanent resident or nonpermanent resident parent); Perm equals 1 if the child
resides with a permanent resident (but not a nonpermanent resident parent); Nonperm equals 1 if the
child resides with a nonpermanent resident parent
(natives are the omitted group); X is a vector of
demographic characteristics of the child, household
head, and the household; and a are the estimated

Health and Medical Care Among Children

1497

Table 1
Weighted Descriptive Statistics of Sample

Native
M or %
Health outcomes
Very good or excellent health
Had a dental visit
Had a doctor visit
Child characteristics
Age
Boy
Race or ethnicity
Non-Hispanic White
Non-Hispanic Black
Hispanic
Non-Hispanic Other
Health insurance
Public
Private
No coverage
Household characteristics
Head age
Head educational attainment
No high school
High school only
More than high school
Head work status
Works
Spent some time unemployed
Out of the labor force
Head marital status
Married
Divorced or separated
Widowed
Never married
Receives food stamps
Receives cash welfare
No. children < 18
No. adults
Own home
Monthly income
Median monthly income
Parental self-reported health
Unweighted person-years
Unweighted persons

Naturalized
SD

M or %

Permanent resident

SD

M or %

SD

Nonpermanent
resident
M or %

SD

80.32%
51.42%
63.23%

81.45%
49.98%
54.26%

77.53%
40.72%
52.03%

75.49%
31.63%
47.11%

8.51
51.23%

4.86

9.46
47.59%

4.81

8.37
50.97%

4.84

7.43
48.75%

4.79

56.91%
25.56%
13.44%
4.09%

26.51%
9.01%
45.44%
19.03%

14.09%
6.12%
68.99%
10.81%

8.54%
3.57%
81.79%
6.10%

42.63%
38.97%
18.40%

37.97%
36.13%
25.90%

42.24%
25.55%
32.21%

48.86%
15.66%
35.48%

36.35

9.13

40.65

9.12

37.87

8.79

35.86

8.43

19.90%
37.71%
42.40%

30.05%
31.52%
38.43%

50.84%
25.68%
23.47%

58.21%
24.20%
17.59%

63.26%
8.86%
27.88%

62.68%
9.79%
27.53%

66.06%
9.35%
24.59%

63.68%
7.88%
28.45%

53.45%

23.57%

2.43%

20.55%

34.01%

11.87%

2.76
1.39
1.87
0.83
46.63%

2,120.40
1,392.54
2,015.03

2.37
0.98
62,037
35,787

72.54%

15.93%

2.49%

9.04%

21.50%

7.19%

2.72
1.31
2.23
0.90
56.47%

2,273.67
1,362.55
2,201.37

2.31
0.94
3,763
2,344

coefficients. We also test the following relations:

a2 = a3, a2 = a4, and a3 = a4.
In all regressions, we correct for the nonindependence of observations due to children contributing
multiple observations within a panel. We report logit coefficients, standard errors, and marginal
effects for all regressions. Marginal effects translate

79.11%

10.45%

1.71%

8.72%

24.05%

9.49%

2.94
1.36
2.28
0.91
45.12%

2,280.55
1,346.46
2,142.68

2.33
0.90
10,400
5,521

77.60%

7.19%

1.13%

14.09%

27.16%

13.13%

2.98
1.35
2.42
1.08
25.67%

2,141.09
1,249.79
1,950.79

2.34
0.90
4,473
2,496

logistic coefficients into percentage point differences.

Childrens health. Table 2 presents the findings
from the analysis of childrens health. Low-income
children residing in naturalized citizen households
do not differ in reported very good or excellent
health compared to their native counterparts.

1498

Ziol-Guest and Kalil

Table 2
Weighted Logistic Regression Results
Very good or excellent health
B
Immigrant status
Naturalized citizen
Permanent resident
Nonpermanent resident
Child characteristics
Age
Boy
Non-Hispanic Black
Hispanic
Non-Hispanic Other
Public health insurance
No health insurance
Household characteristics
Head age
Head no high school
Head more than high school
Head employed
Head unemployed
Head married
Head divorced or separated
Head widowed
Received food stamps
Received cash welfare
No. children < 18
No. adults
Own home
Log monthly income
Parental self-reported health
Constant
Wald chi-square
Psuedo R-square

SE B

ME

)0.02
)0.13**
)0.23***

0.06
0.04
0.05

)0.002
)0.019
)0.035

0.00
)0.07**
)0.26***
)0.18***
)0.08
)0.28***
)0.15***

0.00
0.02
0.03
0.03
0.05
0.03
0.03

0.01***
)0.07*
0.15***
)0.07**
)0.11**
0.04
)0.01
0.01
0.04
0.11**
)0.03***
0.01
)0.01
)0.05***
)0.86***
3.95***
5,702.76***
0.11

0.00
0.03
0.03
0.03
0.04
0.04
0.04
0.08
0.03
0.04
0.01
0.01
0.03
0.01
0.01
0.09

Dental visit
B

Doctor visit

SE B

ME

)0.04
)0.13***
)0.34***

0.05
0.03
0.05

)0.010
)0.033
)0.084

)0.000
)0.010
)0.039
)0.026
)0.012
)0.040
)0.022

0.12***
)0.06**
)0.30***
)0.15***
)0.15***
0.00
)0.83***

0.00
0.02
0.03
0.03
0.04
0.03
0.03

0.001
)0.011
0.020
)0.011
)0.015
0.005
)0.001
0.001
0.006
0.016
)0.005
0.002
)0.002
)0.007
)0.122

0.01***
)0.18***
0.30***
)0.01
0.00
0.05
)0.05
)0.29***
0.14***
0.01
0.00
)0.23***
0.17***
0.06***
)0.02
)1.11***
6,290.92***

0.00
0.03
0.02
0.02
0.03
0.03
0.03
0.07
0.03
0.03
0.01
0.01
0.02
0.01
0.01
0.07
0.1

SE B

ME

)0.16***
)0.13***
)0.28***

0.04
0.03
0.04

)0.039
)0.030
)0.068

0.031
)0.015
)0.075
)0.039
)0.037
0.000
)0.201

)0.03***
)0.02
)0.42***
)0.30***
)0.30***
0.16***
)0.76***

0.00
0.02
0.03
0.03
0.04
0.03
0.02

)0.008
)0.005
)0.101
)0.072
)0.074
0.036
)0.187

0.001
)0.045
0.075
)0.001
)0.001
0.013
)0.012
)0.072
0.034
0.002
0.001
)0.056
0.042
0.014
)0.005

0.00
)0.10***
0.27***
)0.04
)0.01
0.05
0.06
0.04
0.10***
0.07*
)0.17***
)0.10*
0.05***
0.06***
0.14
0.80***
4,257.11***

0.00
0.02
0.02
0.02
0.03
0.03
0.03
0.06
0.02
0.03
0.01
0.01
0.02
0.01
0.01
0.07

0.000
)0.025
0.064
)0.010
)0.001
0.013
0.014
0.010
0.023
0.018
)0.040
)0.025
0.012
0.015
0.032

0.06

Note. Standard errors are adjusted for individuals contributing more than one observation to the analysis. ME are marginal effects. All
models also include survey panel fixed effects. Regressions are weighted.
*p < .05. **p < .01. ***p < .001.

However, children in non-naturalized households

(permanent and nonpermanent residents) are less
likely to be reported in very good or excellent
health compared to children in native households.
Children of nonpermanent residents are also less
likely to be reported in very good or excellent
health than children in naturalized citizen households (v2 = 9.42; p < .01). The two groups of children in non-naturalized citizen households do not
differ from one another, however. The pattern of
results is similar if we use the original 5-point measure of child health as the outcome variable in an
ordered logistic regression.
Marginal effects suggest that children residing in
nonpermanent resident households are 3.5 percent-

age points less likely to be reported in very good or

excellent health than children in native households.
Given that on average (across all children in the
sample) 80% are in very good or excellent health,
this is a relatively modest 17.5% difference.
Childrens health care utilization. Table 2 also presents findings from the regression estimating Equation 1 for whether or not the child had a dental
visit in the past 12 months. Controlling for all of
the covariates, the childs parental citizenship status
has an independent significant association with
having seen a dentist in the past 12 months. Specifically, children residing in non-naturalized citizen
households are less likely to have had a recent
dental visit compared to low-income natives.

Health and Medical Care Among Children

Children residing in a household with a nonpermanent resident parent are also less likely to
have seen a dentist than children in households
with naturalized parents (v2 = 24.51 p < .001). The
pattern of results is similar for these immigrant
groups if a negative binomial regression is used for
the number of dental visits in the past 12 months.
The marginal effects illustrate the effect sizes in
percentage point differences. The children of a nonpermanent resident parent are 8 percentage points
less likely to have had a dental visit in the past
12 months compared to their native counterparts.
This is a moderate 17% difference, given that on
average 49% of the sample has had a dental visit in
the past year. In contrast, children in permanent
resident households are only 3 percentage points
less likely to have had a dental visit (representing a
7% difference) in the past 12 months compared to
their native counterparts.
Table 2 presents the coefficients, standard errors,
and marginal effects from the analysis of whether
the child had any doctor visit in the past
12 months. Children in all three non-native households are less likely to have seen a doctor in the
past year than children of natives; here, the effect
for children of permanent residents is smaller than
the effect for the children of naturalized citizens as
well as nonpermanent residents.
Specifically, children in nonpermanent resident
households are 7 percentage points less likely to
have seen a doctor compared to those in native
households (a relatively modest difference of
about 11% given that 60% of children overall have
seen a doctor in the past year), whereas those
with naturalized or permanent resident parents
were 4 and 3 percentage points less likely to do
so, respectively. Results from a negative binomial
regression on the number of doctor visits yields
similar findings.

Discussion
In line with prior work showing the gaps in health
and health-care use between low-income immigrants and their native counterparts, our work,
using a national sample, illustrates the significantly
less good health and lower frequency of doctor and
dentist visits among low-income immigrants in
recent cohorts. Moreover, our results show the
importance of distinguishing children of nonpermanent residents from other groups, and our results
underscore the idea that those with more precarious immigration statuses show the poorest health

1499

outcomes (Ortega et al., 2007). Our results are

therefore consistent with the hypothesis that families with noncitizen members face barriers, real or
perceived, to using relevant programs (in this case,
health-related programs; Ham, Li, & Shore-Sheppard,
2009).
We can only speculate why households with
nonpermanent residents might be more reluctant,
or less able, to access health and dental care. Parents who are not citizens may not be aware of their
U.S.-born childrens eligibility for these benefits. It
could also be that this group contains an overrepresentation of undocumented parents or family members, in which case, fears of the Immigration and
Naturalization Service (INS) could be a factor
(Yoshikawa & Kalil, 2011). Other studies suggest
that immigrant parents may believe that seeking
assistance for their eligible children will jeopardize
their childrens citizenship status or hinder other
family members efforts to obtain citizenship or
legal status or their ability to re-enter and stay in
the United States (Capps, 2001; Fix & Passel, 1999;
Maloy, Darnell, Nolan, Kenney, & Cyprien, 2000;
Yoshikawa, Lugo-Gil, Chaudry, & Tamis-LeMonda,
2005). A limitation of this analysis is that we could
not determine the citizenship status of the children
themselves; the pattern of results may differ further
depending on whether children in households are
citizens.
Alternative explanations could include a lack of
linguistically and culturally competent health-care
providers, and a lack of outreach efforts to enroll
eligible children and families in public health programs (Flores et al., 2002; Ortega et al., 2007; Yu,
Huang, Schwalberg, & Kogan, 2005). Our data set
is limited in that it does not provide any measures
of parents experiences seeking health care or their
perceptions of the quality of care they have previously received. Thus, we were not able to test these
different hypotheses. These results could also
reflect a widening of the gap in childrens health if
new programs (such as SCHIP and Medicaid
expansions) that were implemented in the late
1990s had differential impacts on young children in
citizen versus immigrant households. For example,
differences in outreach efforts could have resulted
in these programs reaching more native than
immigrant families and better promoting native
childrens health and health care use.
The differences in childrens health and health
care use that we have identified here among immigrant and citizen groups have implications for
efforts to eliminate health-care disparities. If the
particular barriers to immigrants use of programs

1500

Ziol-Guest and Kalil

and support services can be identified, there may

be a role for public policy to intervene.

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