BACKGROUND AND OBJECTIVES

Studies supporta recent decline in public benefit enrollment among immigrant families. We aimed to describe health and resource use, barriers to use, and immigration-related fear in families with undocumented parents compared with families without undocumented parents. We also aimed to assess associations with discontinuation of public benefits and fear of deportation.

METHODS

We assessed immigration concerns and enrollment in Medicaid, Supplemental Nutrition Assistance Program (SNAP), and Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) with an 89-item anonymous, cross-sectional survey of English- and Spanish-speaking caregivers of hospitalized children. Multivariable logistic regression was used to assess associations with discontinuation of public benefits and fear of deportation.

RESULTS

Of 527 families approached, 399 enrolled (105 with 1 or more undocumented parent, 275 with no undocumented parent, and 19 with undisclosed immigration status). Compared with families without undocumented parents, families with undocumented parents had higher levels of poverty and food insecurity. Controlling for perceived eligibility, public benefit use was similar across groups. Of families with undocumented parents, 29% reported public benefit discontinuation because of immigration concerns, and 71% reported fear of deportation. Having an undocumented parent was associated with public benefit disenrollment (odds ratio: 46.7; 95% confidence interval: 5.9–370.4) and fear of deportation (odds ratio: 24.3; 95% confidence interval: 9.6–61.9).

CONCLUSIONS

Although families with undocumented parents had higher levels of poverty and food insecurity compared with families without undocumented parents, public benefit use was similar between groups. Immigration-related fear may be a barrier to public benefit use in this population.

What’s Known on This Subject:

Many children with undocumented parents live in poverty and qualify for government-issued benefits. Studies support a recent decline in public benefit enrollment among immigrant families. However, there are limited data describing undocumented immigrant benefit use and immigration-related concerns.

What This Study Adds:

In this study, we describe significant unmet socioeconomic and health care disparities in children with undocumented parents and demonstrate that undocumented immigration status is associated with disenrollment in public benefits and immigration-related fear.

Children in immigrant families (CIF), defined as either foreign-born children or children with at least 1 foreign-born parent, are a fast-growing population and comprise approximately a quarter of all children in the United States.13  These children face unique socioeconomic and health challenges.4,5  Compared with children from nonimmigrant families, CIF are more likely to live in poverty, be uninsured, and rely on public benefits.1,2,68  A subset of CIF are children with 1 or more undocumented parent, totaling approximately 8% of all US children.9  Children with undocumented parents have even higher socioeconomic disadvantages, with an estimated 75% living below the federal poverty level compared with 51% of CIF.1,10  Approximately 79% of children with undocumented parents are US citizens, and many qualify for public benefits like Supplemental Nutrition Assistance Program (SNAP); Special Supplemental Nutrition Program for Women, Infants, and Children (WIC); Medicaid; and Children’s Health Insurance Program (CHIP).1,911  Given that participation in public benefits is associated with improved educational attainment and physical and mental health in children, these benefits are crucial to mitigate effects of poverty in this population.12,13 

Recent immigration policy has negatively impacted immigrant health and access to public benefits.1423  Under an updated “Inadmissibility on Public Charge Grounds” (“Public Charge”) rule that went into effect in February 2020, the government considered use of certain public benefits (Medicaid for nonpregnant adults, SNAP, and federal housing assistance) when reviewing applications for lawful permanent residence (ie, a green card) or an immigrant visa to come to the United States from abroad. All other types of immigrants, including refugees and asylees, were excluded from the Public Charge test.24  This expanded rule was subsequently revoked in March 2021.25  However, even before the expanded definition of Public Charge was officially implemented, chilling effects among all types of immigrant families were described.2630  Defined as “a usually undesirable discouraging effect or influence,” the chilling effect in this case refers to families who forego public benefits because of a perceived threat of negative legal repercussions, despite having US-citizen children who have legitimate rights to receive them.31 

The temporary expansion of Public Charge was estimated to have a chilling effect on benefit enrollment for millions of CIF.32  Given that parental immigration status is not tracked in most studies, data are limited on children with undocumented parents. Thus, research is needed to further characterize their socioeconomic and health care needs and how immigration-related fear may affect public benefit use.

We aimed to describe differences in health and resource use, barriers to resource use, and immigration-related fear between families with and without undocumented parents. We also aimed to determine if having 1 or more undocumented parent was associated with 2 outcomes: discontinuation of public benefits and fear of deportation.

We conducted a cross-sectional, anonymous, survey-based study at a large quaternary care children’s hospital in Houston, Texas, from March 2019 to September 2019. We included English- and Spanish-speaking primary caregivers of children ≤18 years old admitted to general inpatient pediatric services. Subject recruitment took place on weekdays when study team members did not have clinical commitments. Caregivers had the option of completing the survey in English or Spanish on an electronic tablet (using Research Electronic Data Capture), on paper, or verbally with assistance from a study team member.33,34 

The Baylor College of Medicine Institutional Review Board approved this study. Because of sensitive content (ie, immigration status), we obtained a waiver of signed consent. There was no financial compensation.

Factors that contribute to disparities in immigrant health service use include health care need, resources, predisposing factors, and macrostructural and contextual conditions, as described by Yang and Hwang.35  Consistent with this framework, we designed an 89-item survey assessing child and caregiver demographics, health and resource use, barriers to resource use, and immigration-related fear (Supplemental Fig 3). Survey questions not found on validated tools were developed by the study team on the basis of content expertise and adaptations from existing literature.3638  The survey was created in English and translated into Spanish. Semistructured interviews with caregivers (17 in English, 10 in Spanish) were completed to assess the validity of the survey (Supplemental Table 6). Test–retest reliability with 7 English-speaking caregivers demonstrated good reliability.

Child demographic variables included age, sex, native country of origin, and immigration status. Caregiver demographic variables included age, relation to the child, race and ethnicity, marital status, education level, employment, household income, number of children in the household, primary language, native country of origin, and immigration status. Immigration status was addressed with 2 questions. The first asked about the participant’s immigration status with answer choices: “US citizen,” “lawful permanent resident,” “work or school visa,” “refugee/asylee,” “seeking asylum (in process),” “temporary protected status,” or “undocumented (without papers).” The second asked whether the participant’s child had 1 or more parents or guardians who are living in the United States and undocumented (without papers). If a participant responded with “seeking asylum” or “undocumented” for the first question or “yes” to the second question, the family was considered to have 1 or more undocumented parent.

Health and resource use variables included perceived child health, number of emergency department visits and admissions, on-time well-child checks, food security, caregiver stress, and current or past Medicaid or CHIP, SNAP, and WIC use. Food security was measured with the US Department of Agriculture Household Food Security Survey Module.39  Caregiver stress was measured by using the Perceived Stress Scale.40,41  When applicable, caregivers were asked to select reasons why their child had a delayed well-child check or was not enrolled in Medicaid and CHIP, SNAP, or WIC. Several barriers were listed (including perceived ineligibility due to family income, perceived ineligibility due to immigration status, logistic barriers, and immigration concerns), and families could select more than one response.

Questions about immigration-related fear assessed whether families experienced discrimination, had a family member or friend who was deported in the past year, feared deportation or separation from family, or feared that work, school, or child hospitalization would affect immigration status. We also inquired whether families stopped services from WIC, SNAP, Temporary Assistance for Needy Families, or Medicaid and CHIP because of concerns “about having immigration or citizenship problems.”

All statistical analyses were performed by using SAS (version 9.4; SAS Institute, Inc, Cary, North Carolina). In our first analysis, our exposure variables were demographics, health and resource use, barriers to resource use, and immigration-related fear, with parent documentation status (with versus without undocumented parents) as the outcome. We then performed 3 subanalyses comparing enrollment rates for Medicaid and CHIP, SNAP, and WIC across families with and without undocumented parents while controlling for families with “perceived eligibility” for each resource. Because eligibility for public benefit programs could not be determined for participants without compromising the anonymity of the survey, self-reported perceptions of eligibility were used as a proxy measurement. We used Fisher’s exact tests and χ2 tests for descriptive data. Continuous variables were analyzed with analysis of variance, Student’s t test, or Wilcoxon–Mann–Whitney test.

In our second analysis, we assessed the association of parent documentation status as an exposure with 2 outcomes: discontinuation of public benefits and fear of deportation. We performed 2 multivariable logistic regression analyses with these outcomes. Controlling for collinearity, survey variables with P values of <.2 from univariate analyses for each of these outcomes were considered for our multivariable regression models. Stepwise model selection method was used to conduct multivariable logistic regression analysis with calculated odds ratios and corresponding 95% confidence intervals (CIs). Variables with P values of <.05 were chosen for our final multivariable logistic regression model.

Of 1075 potential participants during the study period, 527 were approached and 399 enrolled (76% response rate). Of these participants, 105 reported having 1 or more undocumented parent, and 19 did not disclose immigration status (Fig 1). Data for participants who did not disclose immigration status can be found in Supplemental Tables 710.

FIGURE 1

Diagram detailing the flow of participants through the enrollment process.

FIGURE 1

Diagram detailing the flow of participants through the enrollment process.

Close modal

Caregiver age, child age, child sex, caregiver type, and caregiver marital status did not differ between children with and without undocumented parents. A higher proportion of caregivers among families with undocumented parents identified as Latino or Hispanic anddid not speak English. Caregivers among families with undocumented parents had lower education and income levels compared with caregivers from families without undocumented parents (Table 1).

TABLE 1

Comparison of Demographics in Families With 1 or More Undocumented Parent Versus Families Without Undocumented Parents

Undocumented (n = 105), n (%)Documented (n = 275), n (%)P
Child age, y   .44 
 ≤5 72 (69) 177 (64) — 
 >5 33 (31) 98 (36) — 
Child female sex 52 (50) 127 (46) .58 
 Not reported 1 (0) — 
Caregiver   >.99 
 Mother or father 101 (96) 264 (96) — 
 Stepmother or stepfather 2 (1) — 
 Legal guardian 3 (3) 9 (3) — 
 Not reported 1 (1) — 
Caregiver age, mean (range) 32 (19–56) 34 (18–72) .44 
 Not reported 12 (11) 25 (9) — 
Survey language   <.001 
 English 32 (30) 256 (93) — 
 Spanish 73 (70) 19 (7) — 
Racea    
 Asian 4 (4) 17 (6) .37 
 Black 4 (4) 48 (17) <.001 
 White 31 (30) 137 (50) <.001 
 American Indian 4 (4) 11 (4) .93 
 Native Hawaiian or other Pacific Islander 1 (0) .54 
 Other 60 (57) 69 (25) <.001 
 Not reported 3 (3) 7 (3) — 
Hispanic, Latino, Spanish 98 (93) 122 (44) <.001 
 Not reported 1 (0) — 
Marital status   .27 
 Single, separated, divorced, widowed 33 (31) 104 (38) — 
 Married or cohabitation 71 (68) 171 (62) — 
 Not reported 1 (1) — 
Primary language   <.001 
 English 25 (24) 233 (85) — 
 Spanish 79 (75) 37 (13) — 
 Other 1 (1) 5 (2) — 
Caregiver born in the United States 21 (20) 221 (80) <.001 
 Not reported 2 (1) — 
Child is US citizen 91 (87) 269 (98) <.001 
 Not reported 1 (1) — 
Caregiver education level   <.001 
 Some high school or less 37 (35) 22 (8) — 
 High school graduate or some college 60 (57) 176 (64) — 
 College degree 3 (3) 48 (18) — 
 Master's degree or above 3 (3) 28 (10) — 
 Not reported 2 (2) 1 (0) — 
Children <18 in the household   .22 
 0–1 22 (21) 82 (30) — 
 2–3 66 (63) 155 (56) — 
 4 or more 17 (16) 38 (14) — 
Caregiver employed 32 (30) 160 (58) <.001 
 not reported 2 (2) 7 (3) — 
Caregiver income, $   <.001 
 <30 000 51 (49) 60 (22) — 
 30 000–59 000 19 (18) 49 (18) — 
60 000 5 (5) 108 (39) — 
 Not reported 30 (28) 58 (21) — 
Payer typea    
 Medicaid or CHIP 79 (75) 152 (55) <.001 
 Private 9 (9) 115 (42) <.001 
 Tricare 1 (1) 3 (1) >.99 
 Uninsured 16 (15) 13 (5) <.001 
 Other 1 (1) 1 (0) .47 
 Not reported 1 (1) — 
Undocumented (n = 105), n (%)Documented (n = 275), n (%)P
Child age, y   .44 
 ≤5 72 (69) 177 (64) — 
 >5 33 (31) 98 (36) — 
Child female sex 52 (50) 127 (46) .58 
 Not reported 1 (0) — 
Caregiver   >.99 
 Mother or father 101 (96) 264 (96) — 
 Stepmother or stepfather 2 (1) — 
 Legal guardian 3 (3) 9 (3) — 
 Not reported 1 (1) — 
Caregiver age, mean (range) 32 (19–56) 34 (18–72) .44 
 Not reported 12 (11) 25 (9) — 
Survey language   <.001 
 English 32 (30) 256 (93) — 
 Spanish 73 (70) 19 (7) — 
Racea    
 Asian 4 (4) 17 (6) .37 
 Black 4 (4) 48 (17) <.001 
 White 31 (30) 137 (50) <.001 
 American Indian 4 (4) 11 (4) .93 
 Native Hawaiian or other Pacific Islander 1 (0) .54 
 Other 60 (57) 69 (25) <.001 
 Not reported 3 (3) 7 (3) — 
Hispanic, Latino, Spanish 98 (93) 122 (44) <.001 
 Not reported 1 (0) — 
Marital status   .27 
 Single, separated, divorced, widowed 33 (31) 104 (38) — 
 Married or cohabitation 71 (68) 171 (62) — 
 Not reported 1 (1) — 
Primary language   <.001 
 English 25 (24) 233 (85) — 
 Spanish 79 (75) 37 (13) — 
 Other 1 (1) 5 (2) — 
Caregiver born in the United States 21 (20) 221 (80) <.001 
 Not reported 2 (1) — 
Child is US citizen 91 (87) 269 (98) <.001 
 Not reported 1 (1) — 
Caregiver education level   <.001 
 Some high school or less 37 (35) 22 (8) — 
 High school graduate or some college 60 (57) 176 (64) — 
 College degree 3 (3) 48 (18) — 
 Master's degree or above 3 (3) 28 (10) — 
 Not reported 2 (2) 1 (0) — 
Children <18 in the household   .22 
 0–1 22 (21) 82 (30) — 
 2–3 66 (63) 155 (56) — 
 4 or more 17 (16) 38 (14) — 
Caregiver employed 32 (30) 160 (58) <.001 
 not reported 2 (2) 7 (3) — 
Caregiver income, $   <.001 
 <30 000 51 (49) 60 (22) — 
 30 000–59 000 19 (18) 49 (18) — 
60 000 5 (5) 108 (39) — 
 Not reported 30 (28) 58 (21) — 
Payer typea    
 Medicaid or CHIP 79 (75) 152 (55) <.001 
 Private 9 (9) 115 (42) <.001 
 Tricare 1 (1) 3 (1) >.99 
 Uninsured 16 (15) 13 (5) <.001 
 Other 1 (1) 1 (0) .47 
 Not reported 1 (1) — 

“Not reported” subcategories include the number of people that did not respond to the question. —, not applicable.

a

More than 1 response could be selected.

Forty-six percent of families with undocumented parents reported low or very low food security, compared with 21% of families without undocumented parents. A lower proportion of children with undocumented parents had a primary care physician (83% vs 97%). A higher proportion of children with undocumented parents were uninsured (15% vs 5%) and had delays in obtaining medications because of cost (23% vs 9%). There was no difference in perceived child health or perceived caregiver stress across groups (Table 2).

TABLE 2

Comparison of Health and Resource Use in Families With 1 or More Undocumented Parent Versus Families Without Undocumented Parents

Undocumented (n = 105), n (%)Documented (n = 275), n (%)P
Perceived child health   >.99 
 Excellent 39 (37) 99 (36) — 
 Good 44 (42) 118 (43) — 
 Fair 18 (17) 47 (17) — 
 Poor 4 (4) 11 (4) — 
Perceived stress   .63 
 Low 43 (44) 111 (41) — 
 Moderate 52 (49) 148 (54) — 
 High 7 (7) 13 (5) — 
 Not reported 3 (3) 3 (1) — 
Caregiver has seen psychiatrist or therapist 13 (12) 77 (28) .001 
 Not reported 1 (1) 10 (4) — 
Low or very low food security 48 (46) 57 (21) <.001 
 Not reported 6 (6) 10 (4) — 
Regular PCP 87 (83) 266 (97) <.001 
 Not reported 1 (1) 1 (0) — 
On-time well-child check 89 (85) 256 (93) .07 
 Not reported 4 (4) 2 (1) — 
Delay in filling medication for child because of cost 24 (23) 26 (9) <.001 
 Not reported 6 (6) 1 (0) — 
No. emergency department or urgent care visits for child in the past year   .82 
 0 41 (39) 93 (34) — 
 1–2 44 (42) 126 (46) — 
 3–5 15 (14) 39 (14) — 
 >5 5 (5) 15 (5) — 
 Not reported 2 (1) — 
No. admissions for child in the past y   .72 
 1–2 89 (85) 232 (84) — 
 3–5 10 (9) 33 (12) — 
 >5 4 (4) 8 (3) — 
 Not reported 2 (2) 2 (1) — 
Medicaid or CHIP use (current or past) 87 (83) 188 (68) .003 
 Not reported 1 (1) — 
Current SNAP use 42 (40) 81 (29) .05 
 Not reported 1 (0) — 
SNAP use (current or past) 58 (55) 127 (46) .13 
 Not reported 2 (1) — 
Current WIC usea 45 (43) 57 (21) <.001 
 WIC use (current or past)a 57 (54) 99 (36) .001 
 Not reported 1 (1) — 
Food bank, pantry use 24 (23) 28 (10) .001 
 Not reported 1 (1) — 
Purchase medications for child in another country 8 (8) 12 (4) .20 
 Not reported — 
Plan to seek follow-up care for child in another country 6 (6) 5 (2) .08 
 Not reported — 
Use of social worker, case worker, or patient navigator to enroll in resources 27 (26) 53 (19) .18 
 Not reported 1 (1) 4 (1) — 
Immigration lawyer   <.001 
 Yes 14 (13) 14 (5) — 
 No, but interested in finding one 57 (54) 9 (3) — 
 No, not applicable to me 26 (25) 237 (86) — 
 Not reported 8 (8) 15 (5) — 
Undocumented (n = 105), n (%)Documented (n = 275), n (%)P
Perceived child health   >.99 
 Excellent 39 (37) 99 (36) — 
 Good 44 (42) 118 (43) — 
 Fair 18 (17) 47 (17) — 
 Poor 4 (4) 11 (4) — 
Perceived stress   .63 
 Low 43 (44) 111 (41) — 
 Moderate 52 (49) 148 (54) — 
 High 7 (7) 13 (5) — 
 Not reported 3 (3) 3 (1) — 
Caregiver has seen psychiatrist or therapist 13 (12) 77 (28) .001 
 Not reported 1 (1) 10 (4) — 
Low or very low food security 48 (46) 57 (21) <.001 
 Not reported 6 (6) 10 (4) — 
Regular PCP 87 (83) 266 (97) <.001 
 Not reported 1 (1) 1 (0) — 
On-time well-child check 89 (85) 256 (93) .07 
 Not reported 4 (4) 2 (1) — 
Delay in filling medication for child because of cost 24 (23) 26 (9) <.001 
 Not reported 6 (6) 1 (0) — 
No. emergency department or urgent care visits for child in the past year   .82 
 0 41 (39) 93 (34) — 
 1–2 44 (42) 126 (46) — 
 3–5 15 (14) 39 (14) — 
 >5 5 (5) 15 (5) — 
 Not reported 2 (1) — 
No. admissions for child in the past y   .72 
 1–2 89 (85) 232 (84) — 
 3–5 10 (9) 33 (12) — 
 >5 4 (4) 8 (3) — 
 Not reported 2 (2) 2 (1) — 
Medicaid or CHIP use (current or past) 87 (83) 188 (68) .003 
 Not reported 1 (1) — 
Current SNAP use 42 (40) 81 (29) .05 
 Not reported 1 (0) — 
SNAP use (current or past) 58 (55) 127 (46) .13 
 Not reported 2 (1) — 
Current WIC usea 45 (43) 57 (21) <.001 
 WIC use (current or past)a 57 (54) 99 (36) .001 
 Not reported 1 (1) — 
Food bank, pantry use 24 (23) 28 (10) .001 
 Not reported 1 (1) — 
Purchase medications for child in another country 8 (8) 12 (4) .20 
 Not reported — 
Plan to seek follow-up care for child in another country 6 (6) 5 (2) .08 
 Not reported — 
Use of social worker, case worker, or patient navigator to enroll in resources 27 (26) 53 (19) .18 
 Not reported 1 (1) 4 (1) — 
Immigration lawyer   <.001 
 Yes 14 (13) 14 (5) — 
 No, but interested in finding one 57 (54) 9 (3) — 
 No, not applicable to me 26 (25) 237 (86) — 
 Not reported 8 (8) 15 (5) — 

“Not reported” subcategories include the number of people that did not respond to the question. —, not applicable.

a

This question was only offered to families with children <5 years old

There was no difference between groups in emergency department visits or hospital admissions in the year before enrollment. Medicaid and CHIP (75% vs 55%) and WIC use (43% vs 21%) were significantly higher in families with undocumented parents, whereas 45% of families with undocumented parents reported SNAP use compared with 29% of families without undocumented parents (P = .05) (Table 2).

In a subgroup analysis of participants with perceived benefit eligibility, families with undocumented parents did not have significantly higher rates of Medicaid (85.9% vs 83.1%; P = .55), SNAP (49.4% vs 52.3%; P = .67), or WIC (64% vs 50%; P = .05) use. Of families with perceived eligibility for SNAP, families with undocumented parents reported higher levels of food insecurity compared with families without undocumented parents (47.1% vs 23.7%; P < .001). We found similarly high levels of food insecurity among families with perceived eligibility for WIC (52.9% vs 19.1%; P < .001).

Both groups reported lack of insurance as the top reason for missing well-child checks. Families with undocumented parents reported ineligibility because of citizenship status as the top reason for not being enrolled in Medicaid and CHIP, followed by insurance being cut off or expired. Families without undocumented parents reported ineligibility because of income level, followed by preference for another type of insurance.

Families with undocumented parents reported immigration concerns as the top reason for not being enrolled in SNAP, followed by enrollment and application process difficulties. Families without undocumented parents reported ineligibility because of income level, followed by not needing the resource.

Ineligibility because of age was the top reason why families with and without undocumented parents were not enrolled in WIC. Families with undocumented parents reported immigration-related concerns as the second-highest reason for nonenrollment in WIC, whereas families without undocumented parents reported ineligibility due to income level (Table 3).

TABLE 3

Comparison of Barriers to Resource Use in Families With 1 or More Undocumented Parent Versus Families Without Undocumented Parents

Undocumented, n (%)Documented, n (%)P
Reasons for not having a well-child check on time 12 17  
 Lack of insurance 7 (58) 5 (29) .12 
 Trouble finding a PCP who accepts my insurance 1 (8) .39 
 Cannot afford it 5 (42) 1 (6) .02 
 Concerns about problems with immigrationa N/A 
 Difficulty scheduling an appointment or finding a doctor 1 (8) 2 (12) >.99 
 Transportation issues 1 (8) 4 (24) .62 
 Do not have time 2 (12) .51 
 Moved recently 2 (17) 4 (24) >.99 
 Difficulty understanding English 1 (8) .39 
 Did not know this was important 1 (8) 1 (6) >.99 
 Other 1 (8) 5 (29) .36 
 Not reported 1 (8) N/A 
Reasons for not currently using Medicaid or CHIP 25 123  
 Not eligible because income too high 3 (12) 83 (68) <.001 
 Not eligible because of citizenship status 7 (28) 3 (2) <.001 
 Concerns about problems with immigrationa 2 (8) .03 
 Cutoff or expired 4 (16) 13 (11) .48 
 Enrollment and/or application process difficultiesb 1 (4) 8 (7) >.99 
 Transportation issues 2 (8) 1 (1) .07 
 Prefer another type of insurance 1 (4) 23 (19) .13 
 Otherc 7 (28) 11 (9) .01 
 Not reported 2 (8) 6 (5) N/A 
Reasons for not currently using SNAP 63 193  
 Income too high 8 (13) 108 <.001 
 Child not eligible because of citizenship status 7 (11) 3 (2) .002 
 Concerns about problems with immigrationa 19 (30) <.001 
 Cutoff or expired 6 (10) 13 (7) .41 
 Transportation issues 5 (8) 1 (1) .003 
 Enrollment and/or application process difficultiesd 9 (14) 7 (4) .004 
 Child does not need this resource 3 (5) 55 (28) <.001 
 Otherc 18 (29) 22 (11) .001 
 Not reported 5 (8) 9 (5) N/A 
Reasons for not currently using WIC 60 218  
 Child not eligible because of age 33 (55) 111 (51) .60 
 Income too high 1 (2) 45 (21) <.001 
 Child not eligible because of citizenship status N/A 
 Concerns about problems with immigrationa 7 (12) <.001 
 Cutoff or expired 3 (5) 8 (4) .71 
 Transportation issues 2 (3) 2 (1) .21 
 Missed WIC appointment 4 (7) 7 (3) .26 
 Enrollment and/or application process difficultiesd 3 (5) 2 (1) .07 
 My child does not need this resource 1 (2) 33 (15) .003 
 Otherc 12 (20) 19 (9) .02 
 Not reported 1 (2) 5 (2) N/A 
Undocumented, n (%)Documented, n (%)P
Reasons for not having a well-child check on time 12 17  
 Lack of insurance 7 (58) 5 (29) .12 
 Trouble finding a PCP who accepts my insurance 1 (8) .39 
 Cannot afford it 5 (42) 1 (6) .02 
 Concerns about problems with immigrationa N/A 
 Difficulty scheduling an appointment or finding a doctor 1 (8) 2 (12) >.99 
 Transportation issues 1 (8) 4 (24) .62 
 Do not have time 2 (12) .51 
 Moved recently 2 (17) 4 (24) >.99 
 Difficulty understanding English 1 (8) .39 
 Did not know this was important 1 (8) 1 (6) >.99 
 Other 1 (8) 5 (29) .36 
 Not reported 1 (8) N/A 
Reasons for not currently using Medicaid or CHIP 25 123  
 Not eligible because income too high 3 (12) 83 (68) <.001 
 Not eligible because of citizenship status 7 (28) 3 (2) <.001 
 Concerns about problems with immigrationa 2 (8) .03 
 Cutoff or expired 4 (16) 13 (11) .48 
 Enrollment and/or application process difficultiesb 1 (4) 8 (7) >.99 
 Transportation issues 2 (8) 1 (1) .07 
 Prefer another type of insurance 1 (4) 23 (19) .13 
 Otherc 7 (28) 11 (9) .01 
 Not reported 2 (8) 6 (5) N/A 
Reasons for not currently using SNAP 63 193  
 Income too high 8 (13) 108 <.001 
 Child not eligible because of citizenship status 7 (11) 3 (2) .002 
 Concerns about problems with immigrationa 19 (30) <.001 
 Cutoff or expired 6 (10) 13 (7) .41 
 Transportation issues 5 (8) 1 (1) .003 
 Enrollment and/or application process difficultiesd 9 (14) 7 (4) .004 
 Child does not need this resource 3 (5) 55 (28) <.001 
 Otherc 18 (29) 22 (11) .001 
 Not reported 5 (8) 9 (5) N/A 
Reasons for not currently using WIC 60 218  
 Child not eligible because of age 33 (55) 111 (51) .60 
 Income too high 1 (2) 45 (21) <.001 
 Child not eligible because of citizenship status N/A 
 Concerns about problems with immigrationa 7 (12) <.001 
 Cutoff or expired 3 (5) 8 (4) .71 
 Transportation issues 2 (3) 2 (1) .21 
 Missed WIC appointment 4 (7) 7 (3) .26 
 Enrollment and/or application process difficultiesd 3 (5) 2 (1) .07 
 My child does not need this resource 1 (2) 33 (15) .003 
 Otherc 12 (20) 19 (9) .02 
 Not reported 1 (2) 5 (2) N/A 

More than 1 response for each question could be selected; “not reported” subcategories include the number of people that did not respond to the question; P values calculated differences between families with undocumented parents and families without undocumented parents. N/A, not applicable.

a

Caregiver reported either “concerns about problems with immigration or citizenship” or “fear of ICE or deportation.”

b

Heard about program but did not know how to enroll, enrollment process too confusing, negative experiences with government offices, could not provide documents, language barriers.

c

Never heard of program, did not have time, moved recently, or other.

d

Heard about program but did not know how to enroll, language barriers.

Twenty-nine percent of families with undocumented parents reported discontinuation of public benefits because of immigration concerns, >70% of families with undocumented parents worried about whether a family member, friend, or themselves would be deported or separated from family, and 40% reported that their child had similar concerns. Twenty-four percent of families with undocumented parents worried that their child’s hospitalization would affect their immigration status (Fig 2).

FIGURE 2

Comparison of immigration-related fears in families with 1 or more undocumented parent versus families without undocumented parents. Shown is the percentage of participants who either responded “yes,” “sometimes,” or “often” to the questions; all P values were <.001. ICE, US Immigration and Customs Enforcement.

FIGURE 2

Comparison of immigration-related fears in families with 1 or more undocumented parent versus families without undocumented parents. Shown is the percentage of participants who either responded “yes,” “sometimes,” or “often” to the questions; all P values were <.001. ICE, US Immigration and Customs Enforcement.

Close modal

Univariate analysis displaying factors associated with discontinuation of public benefits and fear of deportation can be found in Supplemental Tables 11 and 12, respectively. In multivariable logistic regression analysis, having undocumented parents or having a family member or friend who was deported were associated with both discontinuation of public benefits (Table 4) and fear of deportation (Table 5). Food insecurity was associated with fear of deportation but not discontinuation of public benefits.

TABLE 4

Multivariable Logistic Regression Analysis Analyzing Variables Associated With Discontinuation of Public Benefits

Adjusted Odds Ratio95% CIP
1 or more undocumented parent 46.7 5.9–370.4 .003 
Family member or friend deported 4.3 1.23–15.0 .02 
Adjusted Odds Ratio95% CIP
1 or more undocumented parent 46.7 5.9–370.4 .003 
Family member or friend deported 4.3 1.23–15.0 .02 

Additional variables with a P value of <.2 in univariate analysis that were included in multivariable analysis but were not found to be significant and were therefore not included in our final model were child age, number of children in the home, caregiver education level, caregiver age, caregiver use of a psychiatrist, caregiver use of an immigration lawyer, child insurance status, Medicaid or CHIP use, SNAP use, delays in obtaining medications because of cost, and having low or very low food security.

TABLE 5

Multivariable Logistic Regression Analysis Analyzing Variables Associated With Fear of Deportation

Adjusted Odds Ratio95% CIP
1 or more undocumented parent 24.3 9.6–61.9 <.001 
Low or very low food security 3.2 1.3–8.3 .006 
Family member or friend deported 6.6 1.4–30.8 .01 
Adjusted Odds Ratio95% CIP
1 or more undocumented parent 24.3 9.6–61.9 <.001 
Low or very low food security 3.2 1.3–8.3 .006 
Family member or friend deported 6.6 1.4–30.8 .01 

Additional variables with a P value of <.2 in univariate analysis that were included in multivariable analysis but were not found to be significant and were therefore not included in our final model were number of children in the home, caregiver education level, caregiver age, caregiver use of a psychiatrist, caregiver use of a case worker or social worker, caregiver use of an immigration lawyer, child insurance status, Medicaid and CHIP use, SNAP use, having a PCP, and delays in obtaining medications because of cost.

We identified significant social and health care needs, disparities in public benefit use, and immigration-related fear among families with undocumented parents. Although approximately one-quarter of our families reported at least 1 undocumented parent, the vast majority of children with undocumented parents were US citizens (87%). Despite the high prevalence of families with mixed immigration status, most existing literature on families with undocumented parents is based on estimates given the sensitivity and privacy concerns of obtaining documentation status.36  Our study is therefore unique in that we anonymously quantified health care and benefit use among undocumented immigrants on behalf of their children.

Social and health care challenges among families with undocumented parents included food insecurity, lack of a primary care provider (PCP), missed well-child checks, and uninsured payer status. These findings are consistent with existing literature describing health disparities in the undocumented immigrant population.9,10  Inconsistent employment, responsibilities of sending remittances to family members in their country of origin, language barriers, lack of education, and immigration-related fear have been described as contributors to food insecurity and health care barriers in the undocumented population.30,42 

In assessing public benefit use, we hypothesized that families with undocumented parents would have decreased resource use compared with families without undocumented parents. We instead identified equivalent or higher levels of public benefit use among families with undocumented parents. This is similar to previous observations describing higher odds of WIC and Medicaid use and similar odds of SNAP use in households with undocumented immigrants compared with households without undocumented immigrants.43 

Despite these findings, it is clear that benefit use among families with undocumented parents is much lower than their need. Excluding families who reported perceived ineligibility, children with undocumented parents had similar rates of SNAP use despite having nearly double the rate of food insecurity. These findings may be explained by bureaucratic obstacles (such as registration systems and paperwork) as well as immigration-related fear described in the undocumented population.42  In addition, food insecurity may be exacerbated in families with undocumented parents because they are only eligible to apply for benefits on behalf of documented family members. Thus, although families with undocumented parents use resources for their children at a similar rate as those without undocumented parents, they do not receive the same level of benefits as families who are all eligible.

Additionally, our study unveiled a significant amount of fear among families with undocumented parents. The majority of these families worried about deportation or separation from family and several reported that their children had similar fears. Approximately one-third of families with undocumented parents reported disenrollment from resources because of immigration-related concerns. Having undocumented parents or a deported family member was associated with higher odds of disenrolling from resources. Furthermore, the top reason for not enrolling in SNAP and WIC among families with undocumented parents was immigration-related concern, which has previously been described.42  However, caregivers did not express similar concerns about enrolling in Medicaid, and the majority of families with undocumented parents perceived to be eligible for Medicaid were enrolled. Although data suggest an overall decline in resource use, including Medicaid, among the immigrant population, immigration-related fear may be a bigger barrier to SNAP and WIC use compared with Medicaid use.26,27,4447  One possible explanation for higher Medicaid enrollment in our undocumented group is that our study was conducted in the inpatient setting. It is possible that our study participants had a higher insured rate than the general population and were more likely to seek care. Additionally, our hospital has mechanisms in place to help families with insurance applications. Although most patients who applied for Medicaid had applications that were still pending at the time of discharge, we did not control for length of stay, and it is possible that some of our patients gained insurance during their hospitalization. Further research is needed to assess why an enrollment discrepancy exists across Medicaid, SNAP, and WIC.

Our study underscores the importance of social needs screening and referral services by pediatric health care providers. It also highlights the impact of fear on seeking public assistance among families with undocumented parents. Providers should take this into consideration and follow American Academy of Pediatrics guidance on counseling families about immigration-related concerns.48  Given the fear associated with using public benefits, disparities in food security among families with undocumented parents may be addressed by connecting families with trusted community organizations and local food banks, which are an underused resource potentially associated with less fear. Finally, the inpatient setting may offer an opportunity to identify and address sensitive stressors unique to families with undocumented parents. However, this must be done while maintaining a safe and protected environment, because a quarter of families with undocumented parents expressed fear that their child’s hospitalization would affect their immigration status.

Our study has several limitations. By limiting inclusion to English- and Spanish-speaking participants, we excluded important perspectives from other undocumented immigrant groups. However, >98% of patients admitted during our study period were either English or Spanish-speaking; thus, we included the vast majority of families on the basis of language. Additionally, 24% of families declined participation, and 5% of enrolled participants did not disclose immigration status, which may have introduced selection bias. Furthermore, our study was performed at a single institution in the inpatient setting, limiting generalizability. However, the inpatient setting may offer the opportunity to interact with several CIF, because children of color are at increased risk of admission to the hospital owing to social and medical disparities. We also captured the perspective of many families whose children did not have established PCPs.49  Additionally, our study is limited by self-reported data; it is possible that some participants misclassified themselves. By completing the analysis on families who reported perceived eligibility for public benefits, we likely missed families who did not know they were eligible and included some families who were ineligible. Finally, our multivariable analyses of variables associated with discontinuation of public benefits and fear of deportation have wide CIs, which likely reflect a small sample size. Larger studies are needed to assess the replicability of our results.

Public benefit use among children with undocumented parents does not match their high levels of need. Immigration-related fear is prevalent among families with undocumented parents, is a barrier to benefit use, and is a common reason for public benefit disenrollment. We highlight the importance of provider education on immigration policies that affect the health of children from families of mixed immigration status, assessing barriers to public benefit enrollment, and appropriately counseling or referring eligible families to community resources. Further research is needed to confirm our findings and to explore effective interventions that mitigate disparities in public benefit use and address fear in this population.

We thank our patient families for taking the time to participate in our study. We also thank the Texas Children’s Hospital social workers, the Houston Immigration Legal Services Collaborative, the Tahirih Justice Center, and the Houston Food Bank for supporting our participants and their families. Finally, we thank Dr Ricardo Quiñonez and the section of Pediatric Hospital Medicine for the opportunity to gain perspectives from their patient families.

Dr Masciale conceptualized and designed the study, acquired data and supervised data collection, analyzed and interpreted the data, drafted the initial manuscript, and critically reviewed and revised the manuscript; Drs Bocchini and Lopez conceptualized and designed the study, supervised data collection, analyzed and interpreted data, and critically reviewed and revised the manuscript; Dr Yu made substantial contributions to the data analysis plan, analyzed and interpreted the data, and critically reviewed and revised the manuscript; Dr Domínguez made substantial contributions to the acquisition of data and critically reviewed and revised the manuscript for important intellectual content; Drs Fredricks and Haq contributed to the conceptualization and design of the study, interpreted data, and critically reviewed and revised the manuscript for important intellectual content; Dr Raphael contributed to the data analysis plan, interpreted data, and critically reviewed and revised the manuscript for important intellectual content; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

FUNDING: No external funding.

     
  • CHIP

    Children’s Health Insurance Program

  •  
  • CI

    confidence interval

  •  
  • CIF

    children in immigrant families

  •  
  • PCP

    primary care provider

  •  
  • SNAP

    Supplemental Nutrition Assistance Program

  •  
  • WIC

    Special Supplemental Nutrition Program for Women, Infants, and Children

1
Woods
T
,
Hanson
D
.
Demographic Trends of Children of Immigrants
.
Washington, DC
:
Urban Institute
;
2016
.
2
Child Trends
.
Immigrant children
.
2018
.
Available at: https://www.childtrends.org/?indicators=immigrant-children. Accessed October 30, 2019
3
Linton
JM
,
Green
A
;
COUNCIL ON COMMUNITY PEDIATRICS
.
Providing care for children in immigrant families
.
Pediatrics
.
2019
;
144
(
3
):
e20192077
4
Linton
JM
,
Choi
R
,
Mendoza
F
.
Caring for children in immigrant families: vulnerabilities, resilience, and opportunities
.
Pediatr Clin North Am
.
2016
;
63
(
1
):
115
130
5
Jarlenski
M
,
Baller
J
,
Borrero
S
,
Bennett
WL
.
Trends in disparities in low-income children’s health insurance coverage and access to care by family immigration status
.
Acad Pediatr
.
2016
;
16
(
2
):
208
215
6
Tolbert
J
,
Orgera
K
,
Singer
N
,
Damico
A
.
Key facts about the uninsured population
.
2018
.
7
Evans
EJ
,
Arbeit
CA
.
What’s the difference? Access to health insurance and care for immigrant children in the US
.
Int Migr
.
2017
;
55
(
5
):
8
30
8
Borjas
GJ
.
Poverty and program participation among immigrant children
.
Future Child
.
2011
;
21
(
1
):
247
266
9
Passel
J
,
Taylor
P
.
Unauthorized immigrants and their U.S.-born children
.
Pew Research Center: Hispanic Trends
.
10
Capps
R
,
Fix
M
,
Zong
J
.
A profile of U.S. children with unauthorized immigrant parents
.
2016
.
11
Migration Policy Institute
.
Children in U.S. immigrant families
.
2010
.
12
Ettinger de Cuba
SA
,
Bovell-Ammon
AR
,
Cook
JT
, et al
.
SNAP, young children’s health, and family food security and healthcare access
.
Am J Prev Med
.
2019
;
57
(
4
):
525
532
13
Sharkey
JR
,
Dean
WR
,
Nalty
CC
.
Child hunger and the protective effects of Supplemental Nutrition Assistance Program (SNAP) and alternative food sources among Mexican-origin families in Texas border colonias
.
BMC Pediatr
.
2013
;
13
:
143
14
Allen
CD
.
Who loses public health insurance when states pass restrictive omnibus immigration-related laws? The moderating role of county Latino density
.
Health Place
.
2018
;
54
:
20
28
15
Rhodes
SD
,
Mann
L
,
Simán
FM
, et al
.
The impact of local immigration enforcement policies on the health of immigrant Hispanics/Latinos in the United States
.
Am J Public Health
.
2015
;
105
(
2
):
329
337
16
Vargas
ED
,
Sanchez
GR
,
Juárez
M
.
The impact of punitive immigrant laws on the health of Latina/o populations
.
Polit Policy
.
2017
;
45
(
3
):
312
337
17
Cruz Nichols
V
,
LeBrón
AMW
,
Pedraza
FI
.
spillover effects: immigrant policing and government skepticism in matters of health for Latinos
.
Public Adm Rev
.
2018
;
78
(
3
):
432
443
18
Philbin
MM
,
Flake
M
,
Hatzenbuehler
ML
,
Hirsch
JS
.
State-level immigration and immigrant-focused policies as drivers of Latino health disparities in the United States
.
Soc Sci Med
.
2018
;
199
:
29
38
19
Potochnick
S
,
Chen
JH
,
Perreira
K
.
Local-level immigration enforcement and food insecurity risk among Hispanic immigrant families with children: national-level evidence
.
J Immigr Minor Health
.
2017
;
19
(
5
):
1042
1049
20
Hall
E
,
Cuellar
NG
.
Immigrant health in the United States: a trajectory toward change
.
J Transcult Nurs
.
2016
;
27
(
6
):
611
626
21
Vargas
ED
,
Ybarra
VD
.
U.S. citizen children of undocumented parents: the link between state immigration policy and the health of Latino children
.
J Immigr Minor Health
.
2017
;
19
(
4
):
913
920
22
Joseph
TD
.
Falling through the coverage cracks: How documentation status minimizes immigrants’ access to health care
.
J Health Polit Policy Law
.
2017
;
42
(
5
):
961
984
23
Pedraza
FI
,
Nichols
VC
,
LeBrón
AMW
.
Cautious citizenship: the deterring effect of immigration issue salience on health care use and bureaucratic interactions among Latino US citizens
.
J Health Polit Policy Law
.
2017
;
42
(
5
):
925
960
24
Immigrant Legal Resource Center
.
Public charge outreach toolkit
.
25
Department of Homeland Security
.
DHS secretary statement on the 2019 public charge rule
.
2021
.
26
Bernstein
H
,
Gonzalez
D
,
Karpman
M
,
Zuckerman
S
.
One in seven adults in immigrant families reported avoiding public benefit programs in 2018
.
Urban Institute
.
27
Bernstein
H
,
Gonzalez
D
,
Karpman
M
,
Zuckerman
S
.
Amid confusion over the public charge rule, immigrant families continued avoiding public benefits in 2019
.
Urban Institute
.
28
Haley
JM
,
Kenney
GM
,
Bernstein
H
,
Gonzalez
D
.
One in five adults in immigrant families with children reported chilling effects on public benefit receipt in 2019
.
29
Wong
T
,
Cha
J
,
Villarreal-Garcia
E
.
The Impact of Changes to the Public Charge Rule on Undocumented Immigrants Living in the U.S
.
Washington, DC
:
US Immigration Policy Center
;
2019
.
30
Munger
AL
,
Lloyd
TD
,
Speirs
KE
,
Riera
KC
,
Grutzmacher
SK
.
More than just not enough: experiences of food insecurity for Latino immigrants
.
J Immigr Minor Health
.
2015
;
17
(
5
):
1548
1556
31
Merriam-Webster
.
Chilling effect
.
Available at: https://www.merriam-webster.com/legal/chilling%20effect. Accessed April 9, 2021
32
Zallman
L
,
Finnegan
KE
,
Himmelstein
DU
,
Touw
S
,
Woolhandler
S
.
Implications of changing public charge immigration rules for children who need medical care
.
JAMA Pediatr
.
2019
;
173
(
9
):
e191744
33
Harris
PA
,
Taylor
R
,
Minor
BL
, et al;
REDCap Consortium
.
The REDCap consortium: building an international community of software platform partners
.
J Biomed Inform
.
2019
;
95
:
103208
34
Harris
PA
,
Taylor
R
,
Thielke
R
,
Payne
J
,
Gonzalez
N
,
Conde
JG
.
Research Electronic Data Capture (REDCap)--a metadata-driven methodology and workflow process for providing translational research informatics support
.
J Biomed Inform
.
2009
;
42
(
2
):
377
381
35
Yang
PQ
,
Hwang
SH
.
Explaining immigrant health service utilization: a theoretical framework
.
SAGE Open
.
2016
;
6
(
2
):
2158244016648137
36
Doran
KM
,
Castelblanco
DG
,
Mijanovich
T
.
Undocumented Latino immigrants and research: New challenges in changing times
.
J Health Care Poor Underserved
.
2018
;
29
(
2
):
645
650
37
Children’s Healthwatch
.
Core survey
.
2018
.
Available at: https://childrenshealthwatch.org/our-survey/. Accessed January 30, 2021
38
Lopez
M
,
Garg
A
,
Greeley
C
,
Bocchini
C
.
Social determinants of health in the inpatient population
.
Pediatric Academic Society National Meeting
;
May 6–9, 2017
;
San Francisco, CA
39
US Department of Agriculture Economic Research Service
.
U.S. household food security module: three-stage design, with screeners
.
2012
.
Available at: https://www.ers.usda.gov/media/8271/hh2012.pdf. Accessed April 9, 2021
40
Cohen
S
,
Kamarck
T
,
Mermelstein
R
.
A global measure of perceived stress
.
J Health Soc Behav
.
1983
;
24
(
4
):
385
396
41
Cohen
S
.
Perceived stress in a probability sample of the United States
. In:
Spacapan
S
,
Oskamp
S
, eds.
The Social Psychology of Health: The Claremont Symposium on Applied Social Psychology
.
New York, NY
:
Sage Publications, Inc
:
1988
;
31
67
42
Hacker
K
,
Anies
M
,
Folb
BL
,
Zallman
L
.
Barriers to health care for undocumented immigrants: a literature review
.
Risk Manag Healthc Policy
.
2015
;
8
:
175
183
43
Girard
C
.
Immigrant use of public assistance and mode of entry: demographics versus dependence
.
Soc Sci Res
.
2015
;
53
:
1
18
44
Trovall
E
.
Houston food pantries help put food on the table as immigrants opt out of food stamps
.
Houston Public Media
.
45
Trovall
E
.
One in seven adults in immigrant families opted out of public benefits in 2018
.
Houston Public Media
.
46
Bovell-Ammon
A
,
de Cuba
SE
,
Coleman
S
, et al
.
Trends in food insecurity and SNAP participation among immigrant families U.S.-born young children
.
Children (Basel)
.
2019
;
6
(
4
):
E55
47
Tolbert
J
,
Artiga
S
,
Pham
O
.
Impact of shifting immigration policy on Medicaid enrollment and utilization of care among health center patients
.
48
American Academy of Pediatrics
.
Immigrant child health toolkit
.
2020
.
49
McKay
S
,
Parente
V
.
Health disparities in the hospitalized child
.
Hosp Pediatr
.
2019
;
9
(
5
):
317
325

Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have no financial relationships relevant to this article to disclose.