Hispanic-Asian Immigrant Inequality in Perceived Medical Need and Access to Regular Physician Care

In the face of continuing large immigrant streams, Hispanic and Asian immigrants’ human and social capital inequalities will heighten U.S. race/ethnic health and health care disparities. Using data from the 2004 and 2008 panels of the Survey of Income and Program Participation, this study assessed Hispanic-Asian immigrant disparity in access to health care, measured by perceived medical need and regular access to a physician. Logistic regression results indicated that Hispanics had lower perceived met medical need and were less likely to see a doctor regularly. These disparities were significantly attenuated by education and health insurance. Assimilation-related characteristics were significantly associated with a regular doctor visit and were not fully mediated by socioeconomic variables. Findings indicate the importance of education above and beyond insurance coverage for access to health care and suggest the potential for public health efforts to improve preventive care among immigrants.     

Disparities in Obesity and Overweight Prevalence Among US Immigrant Children and Adolescents by Generational Status

We examined the prevalence and socio-behavioral correlates of obesity and overweight among 46,707 immigrant and US-born children and adolescents aged 10–17 years. The 2003 National Survey of Children’s Health was used to estimate obesity and overweight prevalence among children in 12 immigrant groups, stratified by race/ethnicity and generational status. Logistic regression was used to examine immigrant differentials in the prevalence and odds of obesity and overweight. Obesity and overweight prevalence varied from a low of 6 and 18% for second-generation Asian immigrants to a high of 24 and 42% for native-born black children (US-born black children with US-born parents), respectively. After adjusting for age, gender, ethnicity, socioeconomic status, perceived neighborhood safety, television viewing, computer use, and physical activity, first-generation immigrant children, overall, had 26% lower odds of obesity than native-born children. Obesity and overweight prevalence was lower for immigrant black and white children than their native-born counterparts, while obesity and overweight prevalence among Hispanic children did not vary significantly by generational status. Compared with native-born white children, the adjusted odds of obesity were 64% higher for native-born blacks, 55% higher for second-generation Hispanic immigrants, and 63% lower for first-generation Asian immigrants. Adjusted immigrant differentials in overweight risks were also marked. Socioeconomic, demographic, and behavioral factors accounted for 61 and 35% of ethnic-immigrant disparities in obesity and overweight prevalence, respectively. Immigrant patterns in childhood obesity and overweight vary substantially by ethnicity and generational status. To reduce disparities, obesity prevention programs must target at-risk children of both immigrant and US-born parents.     

Factors affecting physician visits in Chinese and Chinese immigrant samples

This study examines predictors of Western physician utilization using the Andersen's Behavioral Model of Health Services Use for Chinese elders who reside in Shanghai and immigrant Chinese elders who reside in the US Chinese elders are under-studied relative to their population size and in the US are known to underutilize the healthcare system. Underutilization is highly correlated with poor health and well-being. A unique dataset allowed us to examine predictors of physician utilization for Chinese elders who resided in different countries, in an effort to determine how being an immigrant affects utilization. One hundred and seventy-seven Chinese elders in Boston and 420 Chinese elders in Shanghai participated in the survey. Multiple regression analyses were conducted separately for each sample. Predictors of physician visits for the Boston sample are insurance status, health, and social network, and for the Shanghai sample, use of Chinese medicine, health, and marital status predicted physician visits. We found that access to care variables significantly affects physician utilization for immigrant elders, and that Chinese elders in Shanghai utilize a bicultural system of care. The results indicate that in order to create effective healthcare practices for elder Chinese, alternative healthcare beliefs should be understood by Western physicians.     

Welfare reform, labor supply, and health insurance in the immigrant population

Although the 1996 welfare reform legislation limited the eligibility of immigrant households to receive assistance, many states chose to protect their immigrant populations by offering state-funded aid to these groups. I exploit these changes in eligibility rules to examine the link between the welfare cutbacks and health insurance coverage in the immigrant population. The data reveal that the cutbacks in the Medicaid program did not reduce health insurance coverage rates among targeted immigrants. The immigrants responded by increasing their labor supply, thereby raising the probability of being covered by employer-sponsored health insurance.     

Durational and generational differences in Mexican immigrant obesity: Is acculturation the explanation?

Using the Los Angeles Family and Neighborhood Survey (L.A.FANS-2; n = 1610), we explore the link between Mexican immigrant acculturation, diet, exercise and obesity. We distinguish Mexican immigrants and 2nd generation Mexicans from 3rd+ generation whites, blacks and Mexicans. First, we examine variation in social and linguistic measures by race/ethnicity, duration of residence and immigrant generation. Second, we consider the association between acculturation, diet and exercise. Third, we evaluate the degree to which acculturation, diet, exercise, and socioeconomic status explain the association between race/ethnicity, immigrant exposure to the US (duration since immigration/generation), and adult obesity. Among immigrants, we find a clear relationship between acculturation measures, exposure to the US, and obesity-related behaviors (diet and exercise). However, the acculturation measures do not clearly account for the link between adult obesity, immigrant duration and generation, and race/ethnicity.     

The unintended impact of welfare reform on the medicaid enrollment of eligible immigrants

BACKGROUND: During welfare reform, Congress passed legislation barring legal immigrants who entered the United States after August 1996 from Medicaid for five years after immigration. This legislation intended to bar only new immigrants (post-1996 immigrants) from Medicaid. However it may have also deterred the enrollment of legal immigrants who immigrated before 1996 (pre-1996 immigrants) and who should have remained Medicaid eligible. OBJECTIVES: To compare the Medicaid enrollment of U.S.-born citizens to pre-1996 immigrants, before and after welfare reform, and to determine if variation in state Medicaid policies toward post-1996 immigrants modified the effects of welfare reform on pre-1996 immigrants. DATA SOURCE/STUDY DESIGN: Secondary database analysis of cross-sectional data from 1994-2001 of the U.S. Census Bureau, Annual Demographic Survey of March Supplement of the Current Population Survey. SUBJECTS: Low-income, U.S.-born adults (N=116,307) and low-income pre-1996 immigrants (N=24,367) before and after welfare reform. MEASURES: Self-reported Medicaid enrollment. RESULTS: Before welfare reform, pre-1996 immigrants were less likely to enroll in Medicaid than the U.S.-born (OR=0.55; 95 percent CI, 0.51-0.59). After welfare reform, pre-1996 immigrants were even less likely to enroll in Medicaid. The proportion of immigrants in Medicaid dropped 3 percentage points after 1996; for the U.S.-born it dropped 1.6 percentage points (p=0.012). Except for California, state variation in Medicaid policy toward post-1996 immigrants did modify the effect of welfare reform on pre-1996 immigrants. CONCLUSIONS: Federal laws limiting the Medicaid eligibility of specific subgroups of immigrants appear to have had unintended consequences on Medicaid enrollment in the larger, still eligible immigrant community. Inclusive state policies may overcome this effect.     

Insurance Status and Health Service Utilization Among Newly-Arrived Older Immigrants

Following the 1996 welfare reform, newly arrived older immigrants with less than 5 years of residence (NOIs) have been barred from Medicaid benefits. Neither are they eligible for Medicare due to lack of work history. This study examines the relationship between immigrant status (NOIs or not), health insurance, and health service use among older immigrants; whether insurance mediates the relationship between immigrant status and health service use. The 2000 National Health Interview Survey was analyzed. The sample includes respondents aged 65 or older who are foreign-born (N=1, 178). The adapted Andersen model was used. A series of logistic regressions show insurance is a complete mediator between immigrant status and health service use among older immigrants. Immigrant status was significantly related to the mediator, health insurance; older immigrants with longer than 5 years of residence were 31 times more likely than NOIs to have health insurance in terms of odds. Also, different from health service use among U.S.-born older adults, older immigrants’ service use is significantly related to their insurance status. There was no direct relationship between immigrant status and health service use.     

Ethnic Disparities in Self-Reported Oral Health Status and Access to Care among Older Adults in NYC

There is a growing burden of oral disease among older adults that is most significantly borne by minorities, the poor, and immigrants. Yet, national attention to oral heath disparities has focused almost exclusively on children, resulting in large gaps in our knowledge about the oral health risks of older adults and their access to care. The projected growth of the minority and immigrant elderly population as a proportion of older adults heightens the urgency of exploring and addressing factors associated with oral health-related disparities. In 2008, the New York City Health Indicators Project (HIP) conducted a survey of a representative sample of 1,870 adults over the age of 60 who attended a random selection of 56 senior centers in New York City. The survey included questions related to oral health status. This study used the HIP database to examine differences in self-reported dental status, dental care utilization, and dental insurance, by race/ethnicity, among community-dwelling older adults. Non-Hispanic White respondents reported better dental health, higher dental care utilization, and higher satisfaction with dental care compared to all other racial/ethnic groups. Among minority older adults, Chinese immigrants were more likely to report poor dental health, were less likely to report dental care utilization and dental insurance, and were less satisfied with their dental care compared to all other racial/ethnic groups. Language fluency was significantly related to access to dental care among Chinese immigrants. Among a diverse community-dwelling population of older adults in New York City, we found significant differences by race/ethnicity in factors related to oral health. Greater attention is needed in enhancing the cultural competency of providers, addressing gaps in oral health literacy, and reducing language barriers that impede access to care.     

Risk and Protective Factors in the Perceived Health of Children of Immigrants

A theoretical model of risk and protective factors affecting the perceived health of children of immigrants in the United States was tested using data from the 2002 National Survey of America's Families. The dataset provided a nationally representative sample of 5764 children in immigrant families. The model explained 9% of the variance in perceived health, 31% of the variance in health insurance status, and 9% of the variance in having a usual source of health care. Perceived health was directly affected by societal reception (based on race/ethnicity) and family income. Health insurance served as a mediating factor between perceived health and familyincome, governmental reception (i.e., immigration status), and citizenship. Having a usual source of care did not affect perceived health, nor did other hypothesized factors, including family composition, state-level concentration of co-national immigrants, and state welfare safety nets. Implications for health policy and future research are discussed.     

Healthcare Coverage and Use Among Undocumented Central American Immigrant Women in Houston,Texas

We investigated the prevalence and correlates of having current healthcare coverage and of having a usual formal source of care among undocumented Central American immigrant women. Participants were recruited using respondent driven sampling. Thirty-five percent of participants had healthcare coverage and 43 % had a usual formal source of care. Healthcare coverage was primarily through the local indigent healthcare program and most of those with a usual formal source of care received care at a public healthcare clinic. Having healthcare coverage and having a usual formal source of care were both associated with older age; having a usual formal source of care was also marginally associated with increased time of residence in the US and increased income security. The primary barriers to healthcare use were not having money or insurance, not knowing where to go, and not having transportation. Healthcare interventions may benefit from targeting young and newly arrived immigrants and addressing the structural and belief barriers that impede undocumented immigrant women’s use of healthcare services.     

Utilization of Maternal Health Care Among Immigrant Mothers in New York City, 2016–2018

Immigrant women represent half of New York City (NYC) births, and some immigrant groups have elevated risk for poor maternal health outcomes. Disparities in health care utilization across the maternity care spectrum may contribute to differential maternal health outcomes. Data on immigrant maternal health utilization are under-explored in the literature. We conducted a cross-sectional analysis of the population-based NYC Pregnancy Risk Assessment Monitoring System survey, using 2016–2018 data linked to birth certificate variables, to explore self-reported utilization of preconception, prenatal, and postpartum health care and potential explanatory pathways. We stratified results by maternal nativity and, for immigrants, by years living in the US; geographic region of origin; and country of origin income grouping. Among immigrant women, 43% did not visit a health care provider in the year before pregnancy, compared to 27% of US-born women (risk difference [RD] = 0.16, 95% CI [0.13, 0.20]), 64% had no dental cleaning during pregnancy compared to 49% of US-born women (RD = 0.15, 95% CI [0.11, 0.18]), and 11% lost health insurance postpartum compared to 1% of US-born women (RD = 0.10, 95% CI [0.08, 0.11]). The largest disparities were among recent arrivals to the US and immigrants from countries in Central America, South America, South Asia, and sub-Saharan Africa. Utilization differences were partially explained by insurance type, paternal nativity, maternal education, and race and ethnicity. Disparities may be reduced by collaborating with community-based organizations in immigrant communities on strategies to improve utilization and by expanding health care access and eligibility for public health insurance coverage before and after pregnancy.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11524-021-00584-5.     

Expanding the Universe of Universal Coverage: The Population Health Argument for Increasing Coverage for Immigrants

As the US recession deepens, furthering the debate about healthcare reform is now even more important than ever. Few plans aimed at facilitating universal coverage make any mention of increasing access for uninsured non-citizens living in the US, many of whom are legally restricted from certain types of coverage. We conducted a critical review of the public health literature concerning the health status and access to health services among immigrant populations in the US. Using examples from infectious and chronic disease epidemiology, we argue that access to health services is at the intersection of the health of uninsured immigrants and the general population and that extending access to healthcare to all residents of the US, including undocumented immigrants, is beneficial from a population health perspective. Furthermore, from a health economics perspective, increasing access to care for immigrant populations may actually reduce net costs by increasing primary prevention and reducing the emphasis on emergency care for preventable conditions. It is unlikely that proposals for universal coverage will accomplish their objectives of improving population health and reducing social disparities in health if they do not address the substantial proportion of uninsured non-citizens living in the US.     

Healthcare Utilization Among Hispanic Immigrants with Diabetes: Investigating the Effect of US Documentation Status

Previous studies have not examined whether documentation status has an effect on healthcare utilization among US Hispanic immigrants with diabetes. A secondary analysis was conducted using data from the Pew Hispanic Center and Robert Johnson Wood Foundation’s 2007 Hispanic Healthcare Survey. Hispanic immigrants diagnosed with diabetes were included in analyses. The association between documentation status and healthcare utilization was assessed using logistic regressions. Of N = 577 Hispanic immigrants with diabetes, 80 % were documented immigrants and 81 % reported having visited a healthcare provider in the last 6 months. Adjusting for confounders, those who were undocumented faced higher odds of having seen a healthcare provider more than 6 months ago or never when compared to those who were documented (OR = 1.79; 95 % CI 1.01, 3.14). Unique opportunities in addressing healthcare disparities can be found in focusing on the Hispanic immigrant population living with diabetes.     

Health care utilization by immigrants in Italy

Healthcare utilization studies show how well documented disparities between migrants and non-migrants. Reducing such disparities is a major goal in European countries. However, healthcare utilization among Italian immigrants is under-studied. The objective of this study is to explore differences in healthcare use between immigrant and native Italians. Cross-sectional study using the latest available (2004/2005) Italian Health Conditions Survey. We estimated separate hurdle binomial negative regression models for GP, specialist, and telephone consultations and a logit model for emergency room (ER) use. We used logistic regression and zero-truncated negative binomial regression to model the zero (contact decision) and count processes (frequency decisions) respectively. Adjusting for risk factors, immigrants are significantly less likely to use healthcare services with 2.4 and 2.7 % lower utilization probability for specialist and telephone consultations, respectively. First- and second-generation immigrants’ probability for specialist and telephone contact is significantly lower than natives’. Immigrants, ceteris paribus, have a much higher probability of using ERs than natives (0.7 %). First-generation immigrants show a higher probability of visiting ERs (1 %). GP visits show no significant difference. In conclusion Italian immigrants are much less likely to use specialist healthcare and medical telephone consultations than natives but more likely to use ERs. Hence, we report an over-use of ERs and under-utilization of preventive care among immigrants. We recommend improved health policies for immigrants: promotion of better information dissemination among them, simplification of organizational procedures, better communications between providers and immigrants, and an increased supply of health services for the most disadvantaged populations.     

Health insurance coverage of immigrants living in the United States: differences by citizenship status and country of origin

OBJECTIVES: This study examined health insurance coverage among immigrants who are not US citizens and among individuals from the 16 countries with the largest number of immigrants living in the United States. METHODS: We analyzed data from the 1998 Current Population Survey, using logistic regression to standardize rates of employer-sponsored coverage by country of origin. RESULTS: In 1997, 16.7 million immigrants were not US citizens. Among non-citizens, 43% of children and 12% of elders lacked health insurance, compared with 14% of non-immigrant children and 1% of non-immigrant elders. Approximately 50% of non-citizen full-time workers had employer-sponsored coverage, compared with 81% of non-immigrant full-time workers. Immigrants from Guatemala, Mexico, El Salvador, Haiti, Korea, and Vietnam were the most likely to be uninsured. Among immigrants who worked full-time, sociodemographic and employment characteristics accounted for most of the variation in employer health insurance. For Central American immigrants, legal status may play a role in high un-insurance rates. CONCLUSIONS: Immigrants who are not US citizens are much less likely to receive employer-sponsored health insurance or government coverage; 44% are uninsured. Ongoing debates on health insurance reform and efforts to improve coverage will need to focus attention on this group.     

Inclusion of immigrant status in smoking prevalence statistics

OBJECTIVES: Data from the 1995-1996 and 1998-1999 Current Population Survey tobacco use supplements were used to examine smoking prevalence statistics by race/ethnicity and immigrant status. METHODS: Smoking prevalence statistics were calculated, and these data were decomposed by country of birth for Asian immigrants to illustrate the heterogeneity in smoking rates present within racial/ethnic groups. RESULTS: Except in the case of male Asian/Pacific Islanders, immigrants exhibited significantly lower smoking prevalence rates than nonimmigrants. However, rates varied according to country of birth. CONCLUSIONS: This research highlights the need to disaggregate health statistics by race/ethnicity, sex, immigrant status, and, among immigrants, country of birth. Data on immigrants' health behaviors enhance the development of targeted and culturally sensitive public health smoking prevention programs.     

Urban employee health insurance reform and the impact on out-of-pocket payment in China

Since the middle of the 1990s, China has undertaken a significant reform in urban employee health insurance programs. Using data from the pilot experiment conducted in Zhenjiang, this study examines changes in the pre- and post-reform distributions of out-of-pocket (OOP) expenditures across four representative groups by chronic disease, income, education, and job status. Major findings suggested increased OOP expenditures for all groups after the reform. However, the redistributions in OOP appear to be in favor of the disadvantaged groups, suggesting a more equitable change led by the reform. This study concludes that the post-reform insurance model did not compromise equity in cost-sharing while containing cost inflation and increasing insurance coverage for the urban population.     

The effect of immigrant generation and duration on self-rated health among US adults 2003–2007

Global self-rated health (SRH) is increasingly a key indicator in the assessment of immigrant health. However, evidence of the impact on SRH of generational status, duration of residence in the US, and socioeconomic status (SES) among immigrants and their offspring is limited and inconsistent. We overcome limitations in existing research on this topic by using a uniquely large and diverse data source, the March Annual Social and Economic Supplement of the Current Population Survey (CPS; 2003–2007) (n = 637,209). As a result, we are able to disaggregate results by race/ethnicity, account for country of origin, and consider the role of multiple dimensions of SES. We find that overall first-generation immigrants in the US have lower odds of poor/fair SRH compared to the third-generation. This association is particularly strong for blacks and Hispanics but not significant for Asians. Among first-generation Asians and Hispanics, longer duration of residence is positively associated with poor/fair SRH. Finally, socioeconomic gradients in SRH tend to be less pronounced among the first-generation (versus the third) and, within the first-generation, among recent arrivals (versus those with longer durations). Our results highlight the importance of explicitly accounting for multiple immigration-related variables and their interactions with race/ethnicity and SES. Otherwise, studies may misestimate SRH differences by race/ethnicity and socioeconomic status. The continued growth of the US immigrant population and the second-generation underscore the need to examine patterns in immigrant health systematically.     

‘I’m not sure if they speak to everyone about this option’: analyzing disparate access to and use of genetic health services in the US from the perspective of genetic counselors

Much research has documented disparities in access to and uses of health care services in the US. With the rise of genomic medicine and its use of complex technology, some scholars are concerned that such inequalities of health care will not only continue but also grow. Drawing on 27 semi-structured interviews with front-line genetic workers – master’s-level genetic counselors – this qualitative study explores the factors they view as contributing to variable uptake of genetic health services among US population groups. Patient-centered factors such as attitudes, norms, and education were perceived by some genetic counselors as explanations for disparities in uptake of genetic services. However, genetic counselors more frequently discussed structural and institutional factors (e.g. cost, insurance, type and location of hospital/clinic, and/or staffing issues) when accounting for different rates of usage of genetic services among populations. The prominence of structural impediments to access found in genetic counselors’ narratives about population differences in the uptake of genetic services suggests that genetic medicine could exacerbate rather than ameliorate health disparities in the US.     

Sociodemographic and economic comparisons of children prescribed longer-acting versus short-acting stimulant medications for attention deficit hyperactivity disorder

Little research has been conducted on sociodemographic and cost disparities regarding the use of longer-acting versus short-acting stimulants in the pediatric population. Demographic characteristics and healthcare expenditures of children taking short-acting stimulants versus longer-acting stimulants for attention deficit hyperactivity disorder (ADHD) were compared. Data from the 2000 and 2001 Medical Expenditure Panel Survey, a nationally representative household survey, were analyzed for 221 children exclusively taking short-acting stimulants and 153 children exclusively taking longer-acting stimulants. No disparities in receiving short-acting as opposed to longer-acting stimulants were found by age, gender, race/ethnicity, region of the country, or insurance status. However, children in the latter group were more likely to come from higher income backgrounds and had greater psychotropic medication costs and total healthcare expenditures. For the most part, sociodemographic disparities in medication treatment for ADHD do not appear to exist once a diagnosis has been made.