Health Insurance Coverage Gaps in U.S.-Adopted Children

Each year, hundreds of thousands of children are adopted in America, yet not all gain health insurance coverage after joining their new families. A study from the University of Maryland (UMD) School of Public Health, published in Health Affairs, highlights significant disparities in coverage based on adoption type (domestic vs. international) and the adoptive parent's citizenship status.

While adopted children often have unique health needs compared to non-adopted children—such as cognitive or physical challenges—a prior study by co-author Jamie Fleishman indicates that those needs were commonly insured across different adoptee groups. She notes, "Our research distinguished between four adoptee types and revealed an alarmingly high uninsured rate for some adopted children, especially internationally adopted ones by non-citizens living in the U.S."

The study found nearly a third (30.7%) of this group have no health insurance.

Jamie Fleishman, who was adopted from China and completed her Master's in Public Health at UMD in 2024, developed this research as part of her master's thesis, focusing on health equity.

The study examined insurance data over five years (2018–2022) for children up to age 17 living with their heads of household using the American Community Survey dataset that includes over three million adopted and non-adopted children.

By differentiating between domestic and international adoptions, and further examining international adoptees by householder citizenship, researchers identified that internationally adopted children by U.S. citizens are eligible for public insurance programs like CHIP or Medicaid similar to U.S.-born children.

"We discovered that adopted children should not be grouped together. International and domestic adoptees differ significantly, as do their adoptive parents' citizenship statuses and socioeconomic factors. Therefore, policies need tailoring to address these differences," said Dahai Yue, co-author, assistant professor at SPH's Department of Health Policy and Management, who advised Fleishman for her MPH degree.

The research analyzed four groups of adopted children in the U.S., comparing them against non-adopted children: domestic adoptions, international adoptions by U.S. citizens, international adoptions by non-U.S. citizens, and children living with biological relatives like grandparents but not their parents.

Internationally adopted children by non-U.S. citizens living in the U.S. had the highest uninsured rate at 30.7%, as well as lower rates of both private and public health insurance compared to other adoptee groups, down by 12.1 percentage points for private insurance and 9.1 percentage points for public.

These non-U.S. citizen adopters were also more likely to be the same race as the child, with incomes below the federal poverty line, and homeownership rates lower than other groups.

The study also found a significantly high uninsured rate (7.3%) for children living with relatives, who also tend to live in low-income families.

"Many factors contribute to these disparities that we did not explore in this study. Nevertheless, the data clearly shows these groups are not homogeneous as previously assumed in some research. These children deserve policy attention to ensure all have access to healthcare in the U.S.," said Yue.