Immigrant Children Face Health Care Barriers as Coverage Policies Tighten

Immigrant children had increased odds of having forgone medical care and difficulty with subspecialty referral when compared with US-born children, according to a recent study published in JAMA Network Open.¹

As of 2021, there were an estimated 3 million children born outside of the US who continued to face inequitable access to health care and health insurance.¹ The federal definition of “qualified noncitizen” allows immigrants access to certain health care programs. These individuals include lawful permanent citizens (green card holders), immigrants under temporary protected status for humanitarian reasons, or survivors of domestic violence or trafficking. Under the Biden administration, the definition of qualified noncitizens eligible for certain health programs was extended to include individuals with Deferred Action for Childhood Arrivals (DACA).²

Immigrants must wait 5 years after receiving their qualified noncitizen status to enroll in Medicaid or the Children’s Health Insurance Program (CHIP). Thirty-eight states and Washington, DC, have waived the waiting period for lawfully present immigrant children as of January 2025. ²

However, under the Trump administration, the definition of "qualified noncitizen" was changed in July 2025 under H.R. 1, limiting eligibility for certain lawfully permanent residents, children, and pregnant persons who would qualify for Medicaid or CHIP if not for their immigration status.²

Behind the Numbers: How Researchers Measured Health Care Access

In this retrospective, cross-sectional study, data was compiled using the National Survey of Children’s Health (NSCH), completed by caregivers of children aged 0 to 17 years. Caregiver response data from 2016 to 2022 was included in the study and weighted to account for nonresponses and reflect the US population.¹

Access to care was measured by evaluating uninterrupted insurance in the past 12 months; having a usual place of primary care; having a usual place for sick care that is not a hospital emergency department; having forgone medical care; and having reported difficulty obtaining subspecialty referrals.

States were assessed and categorized into 3 groups according to responses on their inclusivity of health care and insurance.

• Least inclusive: restrictive eligibility and a required 5-year waiting period.
• Moderately inclusive: limited eligibility and a required 5-year waiting period.
• Most inclusive: insurance access for all children regardless of immigration status and no waiting period.

Multivariable regression models used were adjusted for immigration status, state-level inclusivity, and child and caregiver characteristics (education level, employment status, and household income).

Immigrant Children’s Health Coverage Inequities Exposed

The study sample consisted of 279,546 children, of whom 277,386 (99.2%) had valid immigration status data—representative of a population estimate of 72,473,052 children. Of the sample, 8835 (3.2%) were classified as immigrant children, representing 3,097,329 (4.3%) children nationally. The remaining 96.8% were US-born, representing 69,375,723 (95.7%) children nationally.

Among immigrant children, 1,513,509 (48.9%) were aged 12 to 17 years, 49.8% were female, and 39.8% identified as Hispanic. Regarding race, 19.7% identified as non-Hispanic Asian, 16.5% as non-Hispanic Black, and 18.8% as non-Hispanic White.

Among US-born children, 23,450,439 (33.8%) were aged 12 to 17 years, and 48.8% were female. Of them, 24.9% identified as Hispanic ethnicity, 2.0% as non-Hispanic Asian, 12.9% as non-Hispanic Black, and 51.7% as non-Hispanic White.

When compared with US-born children, immigrant children had higher proportions in the lowest income category: 54.4% lived between 0% and 199% of the federal poverty line (FPL) compared with 40.0% of US-born children.

Immigrant children were also more likely to have been uninsured the entire previous 12 months when compared with US-born children (499,215 [16.5%] versus 3,568,992 [5.2%], respectively). Uninsurance remained higher for immigrant children across all study years, with more than 20% uninsured in 2021.

Compared with US-born children, immigrant children also had lower odds of uninterrupted health insurance (aOR, 0.48; 95% CI, 0.41-0.56), a usual place for primary care (aOR, 0.44; 95% CI, 0.38-0.52), and a usual place for sick care (aOR, 0.62; 95% CI, 0.55-0.70.) They had higher odds of having forgone 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).

In states with the most inclusive policies for health coverage, immigrant children had significantly higher odds of uninterrupted insurance coverage and a usual place of primary care, but no other outcomes. Researchers also found that immigrant children living in the most inclusive policy states in larger magnitude were more likely to have uninterrupted health insurance (aOR, 3.01; 95% CI, 1.89-4.79) when compared with US-born children (aOR, 1.44; 95% CI, 1.26-1.65).

How Could New Federal Policy Changes Impact Immigrant Child Health Coverage?

Despite state-level provisions aimed at amending inequitable health care access for immigrant children, changes made under H.R.1 now exclude DACA recipients from assistance from the Affordable Care Act's marketplace. The broader restrictions are set to take place in January 2027, thus further restricting eligibility for financial help in a marketplace plan for a majority of immigrants, regardless of their status.²

The Congressional Budget Office (CBO) estimates nearly 1 million people will lose insurance due to the immigration-related provisions in H.R. 1. The revised definition of qualified noncitizen will likely result in over 100,000 Medicaid and Medicare enrollees losing coverage, in addition to 10,000 DACA recipients and 1,000 enrolled in basic health plans.²

Irrespective of CBO estimates, this study had limitations. Its large database included the risk of misclassification for individual-level variables. The NSCH asked limited immigration-related questions, preventing analysis of undocumented immigrant children. Furthermore, given one of the primary outcomes was 12-month uninsurance status, short-term residents may have been selected out.¹

“Advancing inclusive state policies for insurance eligibility may help address health access disparities for immigrant children. Improving access to health insurance and health care will be important to ultimately improve health equity for immigrant children in the US,” the study authors concluded.

References

1. Douglas KE, Monuteaux MC, Peeler KR, et al. Health care access outcomes for immigrant children and state insurance policy. JAMA Netw Open. 2025;8(12):e2545826. doi:10.1001/jamanetworkopen.2025.45826

2. Coleman A, Richards C, Collins S, Leonard F. What recent policy changes mean for immigrant health coverage | Commonwealth Fund. The Commonwealth Fund. October 15, 2025. Accessed December 2, 2025. https://www.commonwealthfund.org/publications/explainer/2025/oct/what-recent-policy-changes-mean-immigrant-health-coverage