Adopted children face unequal access to health coverage based on adoption type

People in America adopt hundreds of thousands of children every year, but not all of them receive health insurance once adopted into their second home. A study by University of Maryland (UMD) School of Public Health, out today in Health Affairs, reveals major differences in coverage depending on adoption type (domestic or international) and citizenship status of the adoptive parent. 

"Adopted children generally have more and different health needs – such as cognitive or physical difficulties – than non-adopted children. Previous studies, many of which did not differentiate between different types of adoptees, found adopted children were consistently insured," said study co-author Jamie Fleishman. 

"Our study, which considered four types of adoptee, found a very high uninsured rate for some adopted children – particularly those adopted internationally by non-citizens living in the United States." The study found that almost one-third (30.7%) of the children in this group has no health insurance at all.

Fleishman is a Chinese transnational adoptee who was adopted from China to an American parent. She graduated from UMD in 2024 with a masters in public health (MPH), focusing on health equity, and her master's thesis was the foundation of this study. 

The UMD researchers analyzed insurance coverage over five years (2018 – 2022,) comparing adopted and non-adopted children up to 17 years old who live with their head of household, using data from the American Community Survey (ACS), which includes over three million adopted and non-adopted children. The study distinguishes between international and domestic adoptions and further distinguishes international adoptees by householder citizenship, because international adoptees of U.S. citizens are, similar to a U.S.-born child, eligible for public insurance coverage such as Children's Health Insurance Program (CHIP) or Medicaid. 

"The findings clearly show that we must not treat adopted children as a single group. International adoptees and domestic adoptees are very different. The citizenship status and other factors such as income of adoptive parents are also different. So policies need to be tailored to these differences," said Dahai Yue, co-author and assistant professor in SPH's Department of Health Policy and Management. Yue was Fleishman's MPH advisor. 

The study compared four different groups of adopted children in the U.S. against a control group of non-adopted children: domestic adoptions, international adoptions by U.S. citizens, international adoptions by non-U.S. citizens and children who live with a biological relative, such as a grandparent, but who is not their biological parent. 

Children adopted internationally by non-U.S. citizens living in the U.S. have the highest uninsured rate at 30.7%. They also had lower rates of private and public health insurance than other adoptee groups, by 12.1 percentage points and 9.1 percentage points respectively. The non-U.S. citizens adopting these children were also more likely to be the same race as the child, more likely to have an income below the federal poverty line and less likely to own a home than other groups. 

The study also highlights a significantly high uninsured rate (7.3%) for children who are living with relatives other than their biological parents, and who are also more likely to live in lower-income families. 

"There are likely multiple factors behind these disparities which were not examined in this study. But the data is clear: These groups are not homogenous, despite previous research often treating them as a single population. These children are worthy of policy attention to ensure all children have access to health care in the United States," said Yue. 

Key findings

Children adopted internationally by non-U.S. citizens living in the U.S. 

• Almost one-third (30.7%) of this group has no health insurance at all. 
• This group has lower rates of private health insurance (by 12.1 percentage points) and of public health insurance (by 9.1 percentage points) than other adoptee groups. 
• The non-U.S. citizens adopting these children were also more likely to be the same race as the child, more likely to have an income below the federal poverty line and less likely to own a home than other groups. 

Other adopted and non-adopted children

• Children who are living with relatives other than their biological parents also have a significantly high uninsured rate (7.3%). 
• Children who are the most likely to have private insurance coverage are children adopted domestically (56.2%), children adopted internationally to U.S. citizens (89.1%) and nonadopted children (63.8%). 
• Children who are most likely to have public insurance coverage, such as Medicaid, are those adopted domestically, and those who live with relatives other than their biological father or mother. 
• International adoptees of U.S. citizens were the most insured compared to non-adopted children – in fact, they were more insured than nonadoptees.