Published online September 1, 2006
PEDIATRICS Vol. 118 No. 3 September 2006, pp. e730-e740 (doi:10.1542/peds.2005-2599)
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ARTICLE

Why Are Latinos the Most Uninsured Racial/Ethnic Group of US Children? A Community-Based Study of Risk Factors for and Consequences of Being an Uninsured Latino Child

Glenn Flores, MDa,b,c, Milagros Abreu, MDd and Sandra C. Tomany-Korman, MSa

a Center for the Advancement of Underserved Children, Department of Pediatrics
b Department of Epidemiology, Health Policy Institute, Medical College of Wisconsin
c Children's Research Institute, Children's Hospital of Wisconsin, Milwaukee, Wisconsin
d Boston University School of Public Health, Boston, Massachusetts


   ABSTRACT
TOP
 ABSTRACT
METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
BACKGROUND. Latinos continue to be the most uninsured racial/ethnic group of US children, but not enough is known about the risk factors for and consequences of not being insured in Latino children.

OBJECTIVE. The objective of this study was to identify the risk factors for and consequences of being uninsured in Latino children.

METHODS. A cross-sectional survey was conducted of parents at urban, predominantly Latino community sites, including supermarkets, beauty salons, and laundromats. Parents were asked 76 questions on access and health insurance.

RESULTS. Interviews were conducted of 1100 parents, 900 of whom were Latino. Uninsured Latino children were significantly more likely than insured Latino children to be older (mean age: 9 vs 7 years) and poor (89% vs 72%) and to have parents who are limited in English proficiency (86% vs 65%), non-US citizens (87% vs 64%), and both employed (35% vs 27%). Uninsured Latinos were significantly less likely than their insured counterparts to have a regular physician (84% vs 99%) and significantly more likely not to be brought in for needed medical care because of expense, lack of insurance, difficulty making appointments, inconvenient office hours, and cultural issues. In multivariable analyses, parents who are undocumented or documented immigrants, both parents working, the child's age, and the $4000 to $9999 and $15000 to $19999 family income quintiles were the only factors that were significantly associated with a child's being uninsured; neither Latino ethnicity nor any other of 6 variables were associated with being uninsured. Compared with insured Latino children, uninsured Latino children had 23 times the odds of having no regular physician and were significantly more likely not to be brought in for needed medical care because of expense, lack of health insurance, difficulty making appointments, and cultural barriers.

CONCLUSIONS. After adjustment, parental noncitizenship, having 2 parents work, low family income, and older child age are associated with being an uninsured child, but Latino ethnicity is not. The higher prevalence of other risk factors seems to account for Latino children's high risk for being uninsured. Uninsured Latino children are significantly more likely than insured Latino children to have no regular physician and not to get needed medical care because of expense, lack of health insurance, difficulty making appointments, and cultural barriers. These findings indicate specific high-risk populations that might benefit most from targeted Medicaid and State Child Health Insurance Program outreach and enrollment efforts.

Key Words: uninsured • Hispanic Americans • children • pediatrics • health services research • health status • medical home

Abbreviations: LEP—limited English proficiency • SCHIP—State Children's Health Insurance Program

As has been true for many years, Latinos continue to be the most uninsured racial/ethnic group of children in the United States. The most recent data document that 2.9 million Latino children who are younger than 18 years, or 21%, are uninsured (ie, had no health insurance coverage at any time during the previous year).1 This compares with uninsured rates among children who are younger than 18 years of 7.4% among non-Latino whites,2 14.5% among African Americans,3 and 12.4% among Asian/Pacific Islanders.4

It is unclear why Latinos are the most uninsured racial/ethnic group of US children. Previous work has shown that certain factors that have a high prevalence among Latino children and their families are associated with greater risks for lacking health insurance. For example, being an immigrant or having an immigrant parent,5 living in poverty,6 and having parents with limited English proficiency (LEP)7 are associated with a significantly greater risk for a child's lacking health insurance, and the prevalence of each of these factors is high among Latino children.8 It is unclear, however, which specific factors are significantly associated with Latino children's lack of insurance after adjustment for all relevant confounders. Indeed, no study (to our knowledge) has comprehensively and simultaneously examined immigration status, family income, LEP, child age, number of siblings, parental employment status, duration of parental residence in the United States, parental educational attainment, and marital status and their adjusted associations with lack of insurance in Latino children.

Our primary study goal, therefore, was to examine comprehensively the factors that are associated with lack of insurance coverage among Latino children. A secondary goal was to examine the impact of Latino children's lack of health insurance on access barriers to health care, health status, and use of health services.


   METHODS
TOP
 ABSTRACT
 METHODS
RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
A detailed description of the study methods was provided elsewhere previously.7,9 A summary of selected relevant methods and a comprehensive description of the data analyses are presented herein.

Design/Study Population
From February 2, 2000, to December 22, 2000, a cross-sectional survey was conducted of consecutive primary caregivers (henceforth referred to as parents) of children who were 0 to 18 years of age in the 6 communities in the Greater Boston, MA, metropolitan area with the highest proportion of Latinos (Chelsea, East Boston, Hyde Park, Jamaica Plain, Roxbury, and Roslindale).7,9 We interviewed a consecutive series of parents during time intervals when the primary caregiver was most likely to be going to the market, laundering clothes, or using beauty salons or child care: from 9:00 AM to 6:00 PM on weekdays and 10:00 AM to 3:00 PM on weekends. Within each community, surveys were administered at supermarkets, bodegas, laundromats, beauty salons, restaurants, a homeless shelter, and a child care center. Permission was obtained from business owners to conduct the survey. These community sites were selected to obtain a sample of parents that consisted of both documented and undocumented families in proportions that were reflective of the population in each community.7,9 This sampling method, which is described in detail elsewhere,9 was chosen because traditional census block methods have the potential to undercount undocumented children and their families, given the fear of deportation when a stranger appears at the front door of a dwelling. This sampling method also provides a natural and comparable non-Latino comparison group, in that the non-Latino participants likely represent those who live in the same communities as the Latino participants.

Potential participants were approached when they were exiting the business establishments by trained bilingual research assistants. To be enrolled in the study, candidate participants had to be the primary caregiver parent or legal guardian of a child who was 0 to 18 years of age and currently residing with that participant. The survey took ~20 minutes to complete. Parents received a participation incentive in the form of a cash honorarium or voucher for use at the business establishment. The study was approved by the Institutional Review Board of Boston Medical Center, and oral informed consent was obtained from each participant.

Survey Instrument
The study questionnaire consisted of 74 multiple choice, yes/no, and open-ended questions on the family's sociodemographic characteristics; children's health insurance, access barriers to health care, health status (by parental report), and use of health services; and the parents' knowledge and practices regarding managed care. Questions on sociodemographics, health insurance, access to health care, health status, and use of services were derived from a previously validated questionnaire.7,9 The survey instrument was translated into Spanish and then back-translated by a separate observer to ensure validity. Both the English and the Spanish versions of the survey were piloted extensively at all community sites. Herein we focus on factors that were associated with lack of health insurance coverage in Latino children and the impact of lack of insurance on children's access barriers to health care, health status, and use of health services.

Children's lack of health insurance coverage was determined by asking parents whether their child lacked health insurance at the time of the survey. The child's race/ethnicity was by parental self-report; Latinos were classified as a separate racial/ethnic group, so Latinos are not included in any of the counts for the remaining racial/ethnic groups (including African American, Caribbean black, non-Latino white, African, and Asian/Pacific Islander). In terms of the types of public insurance coverage available at the time of the survey, Massachusetts had a combination type of State Children's Health Insurance Program (SCHIP) that consisted of both Medicaid expansion and a separate limited program that covered primary care and preventive services (the Children's Medical Security Plan) for those who were not eligible for Medicaid, including immigrant children without documentation of citizenship.10

Statistical Analyses
All statistical analyses were performed using SAS Version 8.2 software (SAS Institute, Inc, Cary, NC). Bivariate analysis of categorical variables were completed using the {chi}2 test and Fisher's exact test (in instances in which 25% or more of cells had expected counts <5). The 2-sample Wilcoxon test was used for comparisons of the median number of doctor visits.

Multivariable logistic regression was performed to identify factors that were associated with children's having no health insurance and to examine the association of lacking health insurance with health status, use of health services, and access to care. Negative binomial regression was used to examine factors that were associated with the number of doctor visits in the previous year. Factors that were found to be associated with insurance status either in the bivariate analysis or in previous research were forced into the multivariable models. The following independent variables were included: the child's age, the number of siblings in the family, the parent's educational attainment (high school graduate versus not a high school graduate), parental English proficiency (LEP versus not LEP), parental marital status (married and living with the partner versus other), parental citizenship (US citizen, documented immigrant, or undocumented immigrant), parental employment status (not working, 1 parent working, or 2 parents working), the number of years the parent has lived in the United States (≥10 years versus <10 years), household income in the previous year (<$4000, $4000–$9999, $10000–$14999, $15000–$19999, and ≥$20000), and, when appropriate, the child's race/ethnicity (Latino versus non-Latino). Additional analyses were performed with the identical variables and variable states, except combined family income in the past year was categorized according to the following federal poverty threshold groups: ≤100% of the federal poverty threshold, 101% to 200% of the federal poverty threshold, and >200% of the federal poverty threshold. For multivariable analyses in which insurance status was the outcome, relevant interaction terms also were examined. For examination of the interaction between children's age and parental citizenship status, age was dichotomized as ≥11 versus <11 years, and parental citizenship status was dichotomized as US citizen versus undocumented or documented immigrant. For examination of the interaction between family income and parental employment status, poverty was dichotomized as ≤100% vs >100% of the federal poverty threshold, and parental employment status was dichotomized as unemployed versus at least 1 parent employed.


   RESULTS
TOP
 ABSTRACT
 METHODS
 RESULTS
DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Survey Response Rate and Study Population Race/Ethnicity and Insurance Coverage
Of the 1266 parents invited to enroll in the study, 166 (13%) declined to participate, primarily citing lack of time for survey completion. Nonparticipants did not differ significantly from participants in race/ethnicity or in which of the 6 communities they resided. The race/ethnicity of the 1100 participating children was as follows: 82% were Latino (n = 900), 10% were African American, 4% were Caribbean black, 2% were non-Latino white, 1% were African, 0.3% were Asian/Pacific Islander, and 1% were other/multiple. There were participants from the following Latino subgroups: Dominican (29%), Puerto Rican (25%), Salvadorean (18%), Guatemalan (8%), Colombian (8%), Mexican (2%), and Cuban (1%), with <1% of the remaining participants in each of 8 other Central or South American nationality groups.

As expected (given the study recruitment in predominantly Latino communities), the final study sample included 900 Latino and 200 non-Latino participants; Latino children (18.6%; n = 167) were significantly more likely than non-Latino children (9.5%; n = 19) to be uninsured (P = .002). Latino children were significantly less likely than non-Latino children to have private insurance coverage, at 16.4% vs 27.5%, respectively (P < .001), but there was no significant intergroup difference in public insurance coverage (65% vs 63%, respectively; P = .59).

Comparison of Characteristics of Uninsured and Insured Latino Children
Uninsured Latino children were significantly older than their insured counterparts, but the 2 groups did not differ by gender or in the number of siblings (Table 1). There were no intergroup differences in parental educational attainment, with two thirds of parents in each group not having graduated high school. Parents of uninsured Latino children, however, were significantly more likely than those of insured Latino children to be married, to have LEP, not to be US citizens, to be undocumented immigrants, and to have resided in the United States for <10 years. Parents of uninsured Latino children also were significantly less likely to be unemployed (10% vs 23%) but more likely to live in households where both parents are working (35% vs 27%). Uninsured Latino children were significantly more likely to live in households that were impoverished and had annual combined incomes of $15000 to $20000, whereas insured Latino children were significantly more likely to live in households at 101% to 200% of the federal poverty level and in the highest annual income quintile (>$20000).


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  		TABLE 1 Comparison of the Sociodemographic Characteristics of Uninsured and Insured Latino Children

 
Comparison of Characteristics of Latino and Non-Latino Uninsured Children
Latino and non-Latino uninsured children did not differ significantly in gender, age, or the number of siblings (Table 2). The parents of Latino and non-Latino uninsured children did not differ significantly in educational attainment, marital status, the proportion who had residing in the United States for ≥10 years, the proportion who were living in poverty, or the income quintile. The parents of Latino uninsured children, however, were significantly more likely than their non-Latino counterparts to have LEP, be undocumented immigrants, and to have 1 parent working. The parents of non-Latino uninsured children, in contrast, were significantly more likely than their Latino counterparts to be US citizens, to be unemployed, and to have both parents working.


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  		TABLE 2 Comparison of the Sociodemographic Characteristics of Latino and Non-Latino Uninsured Children

 
Health, Use of Services, and Access to Care for Uninsured and Insured Latino Children
Uninsured Latino children did not differ significantly from insured Latino children in health status or days spent in bed for illness in the past year (Table 3). Uninsured Latino children, however, were significantly more likely than insured Latino children not to have a regular doctor (16% vs 1%; P < .001). Uninsured Latino children also were more likely than their insured counterparts to have made a lower median number of doctor visits in the past year and not to be up to date on vaccinations, but there were no significant intergroup differences in the proportions of children who had gone >1 year without a doctor visit or checkup.


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  		TABLE 3 Comparison of Selected Measures for Health Status, Use of Health Services, and Access to Health Care for Uninsured and Insured Latino Children

 
Several significant intergroup differences were noted in access to health care (Table 3). Uninsured Latino children were significantly more likely than insured Latino children not to have been brought in for needed medical care because of the parents' not being able to afford care, the child's lacking health insurance, health care staff that do not understand the family's culture, difficulty making an appointment, language barriers, and inconvenient doctors' office hours. Insured Latino children, however, were significantly more likely than uninsured Latino children not to have been brought in for needed medical care because of transportation problems and the distance to the health care facility. There were no significant intergroup differences in children's not being brought in for needed care because of immigration problems or too long a wait to see the doctor.

Health, Use of Services, and Access to Care for Latino and Non-Latino Uninsured Children
Latino uninsured children did not differ significantly from non-Latino uninsured children in health status, bed days for illness in the past year, having gone >1 year since the last doctor visit or checkup, or the number of doctor visits in the past year (Table 4). The non-Latino uninsured children, however, were more likely than their Latino uninsured counterparts not to have a regular doctor and not to be up to date on vaccinations.


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  		TABLE 4 Comparison of Selected Measures for Health Status, Use of Health Services, and Access to Health Care for Latino and Non-Latino Uninsured Children

 
Non-Latino uninsured children were more likely than Latino uninsured children not to have been brought in for needed health care because of inability of their parents to afford care and because of lack of insurance coverage for the child. There were no statistically significant intergroup differences, however, in the remaining 8 access barriers to care.

Multivariable Analyses: Factors That Were Associated With Being Uninsured
Older child age, documented or undocumented parental immigrant status, having both parents working, and the $4000 to $9999 and $15000 to $19999 income quintiles were significantly associated with lack of health insurance coverage for children (Table 5). In a separate multivariable analysis (data not shown), a household income ≤100% of the federal poverty level also was associated with more than triple the odds (odds ratio: 3.12; 95% confidence interval: 1.14–8.50) of a child's lacking insurance coverage. Latino ethnicity, however, was not independently associated with being uninsured; neither was the number of siblings or parental educational attainment, marital status, or LEP.


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  		TABLE 5 Multivariable Analyses of Factors Associated With Children's Having No Health Insurance

 
Analyses limited only to Latino subjects revealed that older age, documented or undocumented parental immigrant status, having 1 or both parents working, and the $15000 to $19999 income quintile were significantly associated with a Latino child's lacking health insurance (Table 5). For example, the odds of a Latino child's lacking health insurance were more than 6 times greater when the parent was an undocumented immigrant and approximately twice as great when the parent was a documented immigrant, at least 1 parent was working, or the family income was $15000 to $19999. A separate analysis that examined the 3 federal poverty level categories found no significant association between the poverty level and insurance coverage.

In the separate analyses of potential interactions (data not shown), no significant interaction was found between family income and employment status. One noteworthy significant interaction, however, was found between the child's age and immigration status: among children who were ≥11 years of age, undocumented children had 7 times the adjusted odds of being uninsured compared with children with documented citizenship (odds ratio: 7.02; 95% confidence interval: 3.65–13.50).

Multivariable Analyses: Being Uninsured and Impact on Health, Service Use, and Access
Uninsured children had 33 times the adjusted odds of insured children of having no regular physician (Table 6). Uninsured children also were significantly more likely than insured children not to be brought in for needed medical care because of medical staff's not understanding the family's culture, parents' inability to afford care, the child's having no health insurance, and excessive difficulty in making appointments but were significantly less likely not to be brought in for needed care because of the health care facility's being located too far away. No significant differences were noted between insured and uninsured children in health status, bed days for illness in the past year, going >1 year since the last doctor visit or checkup, the number of doctor visits in the past year, vaccination status, or the remaining 5 access barriers to care.


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  		TABLE 6 Multivariable Analyses of the Association of Lacking Health Insurance With Health Status, Use of Health Services, and Access to Care Among Latino Children

 
In the multivariable analyses that were limited to Latino children, the significant findings for Latino uninsured children were identical to those for uninsured children in general and of similar magnitude (Table 6). Compared with insured Latino children, uninsured Latino children had >23 times the adjusted odds of having no regular physician and significantly greater odds of not being brought in for needed medical care because of medical staff's not understanding the family's culture, parents' inability to afford care, the child's having no health insurance, and excessive difficulty in making appointments.


   DISCUSSION
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
CONCLUSIONS
 REFERENCES
 
Latino Ethnicity and Uninsured Children
After adjustment for relevant covariates, Latino ethnicity is not associated with lack of health insurance coverage in children. Older child age, parental immigrant status, having both parents working, and certain lower family income categories are significantly associated with being uninsured. These findings suggest that the high prevalence of these nonethnic factors may account for the substantial and persistent disparity in lack of insurance coverage for Latino children.1–4 For example, the study findings indicate that populations with higher proportions of older children have a greater risk for being uninsured. Children who are 10 to 19 years of age compose 17.2% of the total Latino population of all ages11 but only 13% of the non-Latino white total population,12 and projections indicate that between 2000 and 2020, the US Latino teen population will increase by 58% compared with only 7% for the total US teen population.13 In 2000, Latinos comprised 13% of the US population14 but accounted for 45% of the foreign-born population, 31% of documented immigrants, and 54% of undocumented immigrants.15 Latinos have the highest employment-to-population ratio (63.7)16 and civilian labor force participation rate (68.2)16 and second highest proportion of families with an employed member (86.7%)17 among all US racial/ethnic groups. Approximately 29% of Latino children who are younger than 18 years live below the federal poverty threshold, a rate that is almost triple that of non-Latino white children and that makes Latinos the second poorest US racial/ethnic group of children.18

Parental Citizenship and Lack of Health Insurance Among Latino Children
Parental citizenship was found to be 1 of the most potent factors associated with lack of health insurance, both for Latino children and for children of all races/ethnicities. Compared with children with citizen parents, children with a documented immigrant parent had double the adjusted odds of being uninsured, and those with an undocumented immigrant parent had >6 times the odds of being uninsured. These findings add to a growing number of studies with similar findings. For example, an analysis of the 1999 National Survey of America's Families revealed that children in low-income noncitizen Latino families were >4 times more likely to be uninsured than those in low-income citizen Latino families (74% vs 17%).19 Similar findings were noted for Asian and African American low-income children.19 Another analysis of data from 2000 showed that one half of low-income noncitizen children and more than one quarter of low-income citizen children with noncitizen parents were uninsured, compared with one sixth of low-income citizen children with citizen parents who lacked insurance.5 In 2002, 22% of low-income citizen children with at least 1 noncitizen parent were uninsured, compared with only 12% of low-income citizen children with citizen parents.20 Our study findings complement these previous studies by demonstrating that having noncitizen parents is significantly associated with children's being uninsured even after adjustment for parental employment, LEP, duration of residence in the United States, Latino ethnicity, and other relevant covariates.

Parental Employment and Lack of Health Insurance Among Latino Children
Having 1 or both parents working was found to place Latino children at double the adjusted odds of being uninsured. The data do not permit identification of the reason for this finding, but 2 national trends offer likely explanations. First, Latinos have a high likelihood of being employed in low-wage jobs that do not offer employer-sponsored insurance.21 In 1996, for example, 61% of Latino workers compared with 77% of non-Latino workers had employer-sponsored coverage,22 and in 1997, only 44% of nonelderly Latinos (<65 years old) had employment-sponsored coverage, compared with nearly three quarters of whites and just over half of African Americans.21 These health insurance coverage disparities for Latinos hold across all income groups and for both part-time and full-time workers.21 It is not surprising, therefore, that nationally, only 41% of Latino children are covered by employer-sponsored insurance compared with 74% of non-Latino white children.23 Second, the percentage of US employers who offered health insurance fell from 69% in 2000 to 60% in 2005.24 This downward trend in employer-sponsored coverage is even more pronounced among the smallest employers (3–9 workers), 57% of whom offered health insurance in 2000, compared with only 47% in 2005. This is particularly relevant for Latino families, because Latino children are significantly more likely than non-Latino white children to be in families who are employed by small firms.25

These 2 trends suggest the possibility of a bleak future for health insurance coverage of Latino children. The greater likelihood of Latino parents' being employed in low-wage jobs that do not offer health benefits coupled with the continued decrease in US businesses that offer health coverage indicate the potential for persistence and even worsening of the substantial disparity in insurance coverage for Latino children.

Family Income, Poverty, and Lack of Health Insurance Among Latino Children
For children across all races/ethnicities, a combined family income of ≤100% of the federal poverty level was associated with more than triple the odds of a child's lacking insurance coverage. These findings are consistent with 2004 national data documenting that 19% of children who are living in poverty are uninsured, compared with 11% of all children.18 Of note, however, is that multivariate analysis by income quintile revealed that only certain income groups ($15000–$19999 and $4000–$9999) were associated with a greater risk for children's being uninsured. The reasons for these associations are unclear, but these findings suggest that a more detailed analysis of specific income categories is warranted when examining factors that are associated with children's lack of insurance coverage.

Among Latino children, a family income ≤100% of the federal poverty level was not associated with greater odds of a child's lacking insurance coverage. In addition, among the income quintiles, only the $15000 to $19999 quintile was associated with a greater risk for children's being uninsured. The reasons for both of these findings could not be determined from the available data and warrant additional study. These results do suggest, however, that a more sophisticated approach may be needed when examining the relationship between family income and children's lack of health insurance among Latinos.

Parental English Proficiency and Lack of Health Insurance Among Latino Children
After multivariate adjustment, parental LEP was not found to be associated with lacking insurance coverage among Latinos or across racial/ethnic groups. Two factors might account for this finding. First, parental citizenship, parental employment, family income, and the child's age seem to be the most important variables associated with children's lack of insurance coverage. Second, parental LEP may only disappear as a factor significantly associated with children's lack of insurance coverage only after proper and comprehensive adjustment for potential confounders, including parental citizenship, duration of parental residency in the United States, parental employment status, parental educational attainment, and family income.

Although parental LEP was not independently associated with children's lack of insurance, these findings should not be construed to mean that language barriers do not act as impediments to insuring uninsured children. Language barriers have been identified as a problem in insuring uninsured children in qualitative research26 and in both national19,27 and state28 surveys.

Consequences of Lacking Health Insurance for Latino Children
For Latino children and children of all races/ethnicities, lacking health insurance was associated with substantially higher odds of having no regular physician. These findings are consistent with many studies during the past 2 decades that have analyzed national, state, and community data sets.29–36 Health insurance coverage has been documented to increase the likelihood of a child's having a medical home, and a medical home is associated with multiple health care benefits, including less emergency department use, fewer hospitalizations, better prevention, fewer unmet needs, increased satisfaction, and lower costs of care.37 Therefore, reducing the disparity in insurance coverage for Latino children not only could enhance their likelihood of having a medical home but also has the potential to improve several of their health care outcomes.

Several access barriers to health care for uninsured children were identified that may have important clinical implications for those who care for the uninsured, such as safety net providers and federally qualified health centers. As one might expect, parents of uninsured Latino children and uninsured children of all races/ethnicities were at significantly greater odds of not bringing their child in for needed medical care because of financial barriers, including not being able to afford care and the child's having no health insurance, but the single most potent variable associated with not bringing in uninsured children for needed care was the health care staff's not understanding the family's culture. This finding underscores the importance of culturally competent pediatric care, especially for families with uninsured children. Difficulty making appointments also was found to be significantly associated with not bringing in uninsured children for needed care; this result is consistent with recent work showing that ease-of-use factors are of increasing importance in ensuring adequate access to health care for racial/ethnic minority children and their families.38

The parents of uninsured children were significantly less likely to have deferred needed care for their children because of the health care facility's being located too far away. The reasons for this finding are unclear and deserve additional study. One possible explanation, however, is that the distance to the health care facility is less of an issue because uninsured children are less likely to have a regular health care provider and more likely to encounter access barriers to care, so finding any facility that provides care to the uninsured is more important than the distance involved in traveling to the facility.

Limitations and Strengths
Certain study limitations should be noted. The study population consisted of urban Latino families from the Northeast United States. The study findings, therefore, may not necessarily generalize to populations that are primarily nonurban or located in other regions of the United States. Although most Latino subgroups were represented in the study population, there were small proportions of Mexican Americans and Cuban Americans, so the results may not generalize to these subgroups. Lack of health insurance was classified using a point-in-time definition; neither continuous lack of insurance during the past 12 months nor the sporadically insured was examined but should be in future research. Although the category and specific name of the child's insurance coverage were recorded, data were not collected on whether the child's insurance coverage was employer sponsored.

Strengths of the current study include the community-based research design; the inclusion of a substantial proportion of undocumented citizen parents; and comprehensive adjustment for immigration status, family income, LEP, child age, the number of siblings, parental employment status, duration of parental residence in the United States, and parental educational attainment and marital status.

Policy Implications
The study findings indicate that there are particularly vulnerable populations of Latino children who would benefit from targeted Medicaid and SCHIP outreach and enrollment. These include older children, those with documented and undocumented immigrant parents, those with 1 or both parents working, and those in families with working-poor incomes. The findings also suggest that there is a high risk for a worsening in the already substantial disparity in lacking health insurance coverage among Latino children, as a result of the greater likelihood of Latino parents' working in low-wage jobs that do not offer employer-sponsored insurance, coupled with the ongoing reduction in US businesses that offer health coverage. Policies are urgently needed to enhance the ability of employers (especially smaller firms) to offer insurance to all employees and their families and to promote take-up of available employer-sponsored insurance by employees through reduction of such cost-related barriers as high premiums and copayments.


   CONCLUSIONS
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
REFERENCES
 
Parental immigrant status, having 2 parents work, low family income, and older child age are associated with significantly higher adjusted odds of being an uninsured child, but Latino ethnicity is not. The higher prevalence of other risk factors seems to account for Latino children's substantially greater risk for being uninsured. Uninsured Latino children are significantly more likely than insured Latino children to have no regular physician and not to get needed medical care because of expense, lack of health insurance, difficulty making appointments, and cultural barriers. These findings indicate specific high-risk populations that might benefit most from targeted Medicaid and SCHIP outreach and enrollment efforts and highlight the need for policies that aim to enhance the ability of employers to offer insurance to employees and their families.


   ACKNOWLEDGMENTS
 
This study was supported by a grant from the Commonwealth Fund and, in part, by grants from the Minority Medical Faculty Development Program and Generalist Physician Faculty Scholars Program of the Robert Wood Johnson Foundation and an Independent Scientist (K02) Award from the Agency for Healthcare Research and Quality.

We thank Justi Santana and Pria Thomas for help with data collection and Jacqueline Gonzales and Sandra Pierce for clerical assistance. We also thank the 3 anonymous reviewers for helpful suggestions and comments. We are grateful to the following business owners and businesses for cooperation and assistance: Rafael Peña and J&J Market; Wash, Dry and Fold; Hilo Market; Green Laundromat; Latino Beauty Salon; the Francisco family and In Plaza Market; and El Platanero. Special thanks are owed to all of the families who participated in this study.


   FOOTNOTES
 
Accepted Feb 13, 2006.

Address correspondence to Glenn Flores, MD, Center for the Advancement of Underserved Children, Department of Pediatrics, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226. E-mail: gflores{at}mcw.edu

The authors have indicated they have no financial relationships relevant to this article to disclose.

This work was presented in part as a platform presentation at the annual meeting of the Pediatric Academic Societies; May 2, 2004; San Francisco, CA; and as a poster at the annual research meeting of AcademyHealth; June 6, 2004; San Diego, CA.


   REFERENCES
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 

  1. Current Population Survey. Table HI01. Health Insurance Coverage Status and Type of Coverage by Selected Characteristics: 2003. Hispanic Origin. Available at: http://pubdb3.census.gov/macro/032004/health/h01_016.htm. Accessed August 25, 2005
  2. Current Population Survey. Table HI01. Health Insurance Coverage Status and Type of Coverage by Selected Characteristics: 2003. White Alone, Not Hispanic. Available at: http://pubdb3.census.gov/macro/032004/health/h01_004.htm. Accessed August 25, 2005
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PEDIATRICS (ISSN 1098-4275). ©2006 by the American Academy of Pediatrics




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