Health Care Access Outcomes for Immigrant Children and State Insurance Policy.

Importance: State policies provide variable health insurance coverage for the 3 million immigrant children in the US, with limited understanding of associations with health care access. Objectives: To (1) examine disparities in health insurance and health care access between immigrant and US-born children and (2) analyze associations of state insurance policies with health care access outcomes for immigrant children. Design, Setting, and Participants: This population-based, retrospective cross-sectional study sampled from the National Survey of Children's Health (2016 to 2022) to facilitate national estimates. Caregivers of children aged 0 to 17 years completed the survey. Data were analyzed from May to December 2024. Exposures: Child immigration status and state-level health insurance policies for immigrant children, categorized as least inclusive (5-year waiting period and eligibility restricted by immigration status), moderately inclusive (waived 5-year waiting period), and most inclusive (waived 5-year waiting period and all immigrant children eligible). Main Outcomes and Measures: Primary outcomes were (1) uninterrupted health insurance in the past 12 months, (2) usual place for primary care, (3) usual place for sick care, (4) having foregone medical care, and (5) having difficulty with referrals. For each outcome, multivariable logistic regression models examined the association with immigration status, adjusting for state-level policies and individual variables, reporting adjusted odds ratios (aORs) and 95% CIs. Results: There were 277 386 children included (population estimate, 72 473 052 children) with 8835 immigrant children (population estimate, 3 097 329 children [4.3%]; 1 513 509 [48.9%] aged 12-17 years; 1 542 412 female [49.8%]) and 268 551 US-born children (population estimate, 69 375 723 children [95.7%]; 23 450 439 [33.8%] aged 12-17 years; 33 876 023 female [48.8%]). In multivariable analyses, immigrant compared with US-born children had lower odds of uninterrupted health insurance (aOR, 0.48; 95% CI, 0.41-0.56), usual place for primary care (aOR, 0.44; 95% CI, 0.38-0.52), and usual place for sick care (aOR, 0.62; 95% CI, 0.55-0.70), and increased odds of having foregone medical care (aOR, 1.61; 95% CI, 1.22-2.14) and difficulty with subspecialty referral (aOR, 1.54; 95% CI, 1.16-2.04). Immigrant children in the most compared with least inclusive policy states had increased odds of uninterrupted health insurance (aOR, 3.01; 95% CI, 1.89-4.79) and usual place for primary care (aOR, 1.61; 95% CI, 1.07-2.41). Conclusions and Relevance: In this cross-sectional study of US children, immigrant compared with US-born children had disparities in health care access, which were attenuated in states with the most inclusive state insurance policies, suggesting that inclusive state insurance eligibility policies for immigrant children may improve health care access outcomes for this population.