Children’s Health Insurance Coverage in Families With Children of Mixed US Citizenship Status

Abstract

This cross-sectional study uses 2023 American Community Survey data to estimate the number of families in the US with children with mixed citizenship status and report their children’s health insurance coverage.

Introduction

Current estimates of the number of families in the US with children with mixed status, defined as at least 1 child with and at least 1 child without US citizenship, are lacking. Children’s eligibility for benefits such as Medicaid can vary by citizenship status¹; consequentially, children in the same family can experience disparate access to care, which has health implications.^2,3 We aimed to estimate the number of families in the US with mixed-status children and report their children’s health insurance coverage.

Methods

This cross-sectional study used publicly available, deidentified data. The University of North Carolina at Chapel Hill Institutional Review Board determined the study not to constitute human participant research. The study followed the STROBE reporting guideline.

We used the 2023 American Community Survey (ACS) 1-year public use microdata file to estimate population sizes.⁴ We estimated the number of families with mixed-status children, which included families with 1 or more caregivers and at least 2 children younger than 18 years (with ≥1 child with and ≥1 child without US citizenship; hereinafter, citizen and noncitizen). We calculated the percentage of families with mixed-status children, using the number of mixed-status families with at least 2 children younger than 18 years as the denominator. See the eMethods in Supplement 1 for more detail.

We estimated the mean number of citizen and noncitizen children per family with mixed-status children. We report race and ethnicity as well as health insurance coverage and type among citizen and noncitizen children. Race and ethnicity and health insurance were self-reported by the household member who completed the 2023 ACS for their household.

We used weights provided by IPUMS USA to represent the US and state populations.⁴ We used household weights to obtain estimations for families and person weights for individual measures. Data were analyzed between November 2025 and August 2026 using StataNow MP Parallel Edition, version 19.5 (StataCorp).

Results

In 2023, there were an estimated 373 104 families with mixed-status children (Table 1); in these families, there were 530 602 citizen children and 495079 noncitizen children (Table 2). Eleven US states had more than 10 000 families with mixed-status children. Families with mixed-status children had a mean (SD) of 2.7 (0.001) children, including 1.5 (0.002) citizen children and 1.4 (0.001) noncitizen children. More than half of all noncitizen and citizen children in families with mixed-status children were Hispanic (52.1% and 53.3%), followed by Asian or Native Hawaiian or Other Pacific Islander (20.6% and 18.9%) and Black (13.5% and 12.7%).

Table 1. Estimated Number of Families With Children With Mixed Citizenship Status, by US State.

State	No. of mixed-status families with ≥2 children	No. of families with mixed-status children	Families with mixed-status children, %a
United States	3 005 750	373 104	12.4
Alabama	18 063	2559	14.2
Alaska	NRb	NR	NR
Arizona	85 057	6984	8.2
Arkansas	17 872	1349	7.5
California	632 683	54 674	8.6
Colorado	42 322	4602	10.9
Connecticut	34 705	6051	17.4
Delaware	NR	NR	NR
District of Columbia	5213	663	12.7
Florida	210 389	35 580	16.9
Georgia	94 717	12 469	13.2
Hawai‘i	NR	NR	NR
Idaho	9573	1665	17.4
Illinois	106 422	9110	8.6
Indiana	36 480	5111	14.0
Iowa	17 735	1631	9.2
Kansas	16 050	784	4.9
Kentucky	12 418	1247	10.0
Louisiana	19 886	3891	19.6
Maine	NR	NR	NR
Maryland	73 798	11 192	15.2
Massachusetts	60 118	10 140	16.9
Michigan	36 486	6074	16.6
Minnesota	31 659	5686	18.0
Mississippi	7843	1883	24.0
Missouri	21 161	4114	19.4
Montana	NR	NR	NR
Nebraska	NR	NR	NR
Nevada	34 957	3317	9.5
New Hampshire	6268	1107	17.7
New Jersey	119 574	17 723	14.8
New Mexico	18 527	1577	8.5
New York	201 750	25 072	12.4
North Carolina	85 640	14 114	16.5
North Dakota	NR	NR	NR
Ohio	38 194	5226	13.7
Oklahoma	25 168	2672	10.6
Oregon	31 126	3462	11.1
Pennsylvania	62 939	12 219	19.4
Rhode Island	9067	1187	13.1
South Carolina	28 398	3480	12.3
South Dakota	4549	759	16.7
Tennessee	39 416	6027	15.3
Texas	452 623	53 235	11.8
Utah	28 590	2763	9.7
Vermont	NR	NR	NR
Virginia	67 779	9359	13.8
Washington	77 847	12 857	16.5
West Virginia	NR	NR	NR
Wisconsin	30 959	3020	9.8
Wyoming	NR	NR	NR

Abbreviation: NR, not reported.

^a The percentage of families with mixed-status children was calculated by dividing the No. of families with mixed-status children by the No. of mixed-status families with at least 2 children younger than 18 years.

^b Estimates marked as NR were suppressed based on Centers for Disease Control and Prevention National Center for Health Statistics data presentation standards. See the eMethods in Supplement 1 for more detail regarding suppression and family definitions.

Table 2. Characteristics of Children in Families With Children With Mixed US Citizenship Status.

Characteristic	Noncitizen children (n = 495 079)	Citizen children (n = 530 602)
No. of children per family, mean (SD)	1.4 (0.001)	1.5 (0.002)
Race and ethnicity, No. (%)
American Indian or Alaska Native, non-Hispanic	0	1258 (0.2)
Asian or Native Hawaiian or Other Pacific Islander, non-Hispanic	102 121 (20.6)	100 123 (18.9)
Black, non-Hispanic	66 786 (13.5)	67 229 (12.7)
Hispanic	257 814 (52.1)	282 760 (53.3)
Multiracial, non-Hispanic	24 113 (4.9)	24 680 (4.7)
White, non-Hispanic	44 245 (8.9)	54 552 (10.3)
Health insurance type, No. (%)
Private	150 243 (30.3)	153 934 (29.0)
Public	231 963 (46.9)	340 895 (64.2)
Uninsured	112 873 (22.8)	35 773 (6.7)

Most citizen children had public insurance (64.2%); 29.0% had private insurance and 6.7% were uninsured (Table 2). Almost half of noncitizen children were publicly insured (46.9%); 30.3% had private insurance and more than 1 in 5 (22.8%) were uninsured.

Discussion

In 2023, more than a quarter million US families had mixed-status children. A total of 6.7% of citizen children and 22.8% of noncitizen children in these families were uninsured. These descriptive findings align with previous research, which found that compared with citizen children in mixed-status families, noncitizen children are at increased risk for being uninsured.⁵ Parents and caregivers may be able to seek care more easily for their insured citizen children, while having to make difficult decisions regarding care for their uninsured noncitizen children. Previous research reported that mixed-insurance status among siblings can also negatively impact the insured child’s access to care.⁶

Policy is a critical lever to affect insurance coverage in families with mixed-status children. Thirty-seven US states and Washington, DC, have opted to waive the 5-year waiting period for legal permanent resident children to access Medicaid, the Children’s Health Insurance Program, or both.⁷ Fourteen states and Washington, DC, use state funds to provide health care coverage for income-eligible immigrant children, regardless of immigration status.¹ These policies promote access to care. Meanwhile, other states and the federal government are implementing harmful policies. For example, North Carolina House Bill 696 authorizes reporting Medicaid applicants “for which citizenship or satisfactory immigration status could not be verified to the United States Department of Homeland Security … for investigation and enforcement.”⁸ Federally, policies in HR 1 redefine which lawfully present immigrants can access benefits such as Medicaid.⁹ Additionally, a new public charge final rule provides immigration officers broader discretion to consider benefit receipt by any family member (including US citizens) of the person applying for a green card or visa in likelihood of becoming a public charge.¹⁰ Such policies could deter families with mixed-status children from applying for benefits for their eligible citizen children, depriving them of benefits they have the right to access.

This study has limitations. We did not disaggregate noncitizens by legal status, which can impact what benefits are accessible. Future research could disaggregate noncitizens by legal status and assess policy impacts on access to benefits and health care. However, noncitizens of varying legal statuses, including those who are documented, are currently threatened by the increasingly anti-immigrant policies being implemented federally. Policies that expand access to health care for all children regardless of citizenship status are fundamental for promoting the future health and well-being of the more than 1 million children in US families with mixed-status children.

Supplement 1.

eMethods

eReferences

Supplement 2.

Data Sharing Statement