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12 Brief communication DIFFERENTIAL ACCESS AND UTILIZATION OF HEALTH SERVICES BY IMMIGRANT AND NATIVE-BORN CHILDREN IN WORKING POOR FAMILIES IN CALIFORNIA Although the proportion of people without health insurance increased gradually nationwide during the 1990s, the rates in California remained higher than in most other states. In 1998, more than 7 million Californians were uninsured, of whom more than 2 million were children.1 Many uninsured children come from poor or near-poor working families who do not have access to employment-based coverage, cannot afford health insurance, choose not to obtain public insurance, or are simply not eligible for public programs .1,2 Among the latter, a large proportion are immigrants. Approximately half of the noncitizens in California were uninsured in 1998.1 Three times more California children from working poor families than U.S. children from working poor families are foreign-born (17 percent vs. 6 percent ).3 Few studies have focused on access to health care for foreign-born children .4,5 Most studies have instead classified children by ethnic group and income,6,7 in part because few data sources collect information on immigrant status.8,9 Two recent studies using the Current Population Survey, which asks about immigrant status, show that foreign-born children in the United States10 and in California1 are at significantly higher risk of being uninsured than native-born children of immigrant or U.S.-born parents. Only a handful of studies on immigrant Latinos in California focus on children, although Latinos are the largest immigrant group in the state, and nearly one in three Latino children are uninsured.1 These studies, which are based on local or purposive samples, also show that low-income immigrant children have decreased health insurance coverage and greater nonfinancial access barriers to care than other low-income children.9"11 However, the extent to which foreign-born uninsured children experience more access barriers than U.S.-born uninsured children has not been examined. Available studies show that children and adolescents with health insurance are more likely to use curative and preventive medical care.12"15 Despite these advantages, states have wide discretion in deciding whether foreign-born children are eligible for public health insurance. Public funding of health services to immigrants, both legal and undocumented, has become a highly charged issue in California.91116,17 The controversy has affected health insurance coverage and access to medical care for immigrants.5,17 For instance, the Personal Responsibility and Work Opportunity ReconciUation Act of 1996 journal of Health Care for the Poor and Underserved · Vol. 13, No. 1 · 2002 Guendelman et al. 13 gave states the option of terminating nonemergency Medicaid coverage for legal immigrants who arrive after August 22,1996. After a five-year stay, the income of an immigrant's sponsor and the immigrant's personal income are to be counted when determining the immigrant's eUgibility for public assistance and Medicaid. This is a marked change from the prior social contract, which treated legal immigrants and U.S. citizens alike in determining income and eligibility.18 While denial of public services to legal and undocumented immigrants is typically aimed at adults, children are often the most affected.16 In California, strong advocacy efforts led the state to continue offering Medi-Cal (CaUfornia 's Medicaid program) coverage to legal immigrant children, irrespective of their date of entry to the United States. Nonetheless, new health insurance expansions under the State Children's Health Insurance Program (SCHIP), enacted by Congress in 1997, exclude undocumented children. In this paper, we examine the joint effects of health insurance status (insured or uninsured) and nativity (foreign- or native-born), on access to care and utilization of health services among children of the working poor in California . We determine if crude differences in access and use by nativity and insurance status persist after adjusting for socioeconomic status, demographic characteristics, and health status. We used a random probabiUty sample of California children from the 1994 National Health Interview Survey (NHIS). The 1994 survey included data on nonfinancial barriers to care relevant to working families, such as care offered after working hours or weekends . The policy implications for extending insurance coverage to lowincome...

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