The role of health insurance in explaining immigrant versus non-immigrant disparities in access to health care: Comparing the United States to Canada

Using a cross-national comparative approach, we examined the influence of health insurance on U.S. immigrant versus non-immigrant disparities in access to primary health care. With data from the 2002/2003 Joint Canada/United States Survey of Health, we gathered evidence using three approaches: 1) we compared health care access among insured and uninsured immigrants and non-immigrants within the U.S.; 2) we contrasted these results with health care access disparities between immigrants and non-immigrants in Canada, a country with universal health care; and 3) we conducted a novel direct comparison of health care access among insured and uninsured U.S. immigrants with Canadian immigrants (all of whom are insured). Outcomes investigated were self-reported unmet medical needs and lack of a regular doctor. Logistic regression models controlled for age, sex, nonwhite status, marital status, education, employment, and self-rated health. In the U.S., odds of unmet medical needs of insured immigrants were similar to those of insured non-immigrants but far greater for uninsured immigrants. The effect of health insurance was even more striking for lack of regular doctor. Within Canada, disparities between immigrants and non-immigrants were similar in magnitude to disparities seen among insured Americans. For both outcomes, direct comparisons of U.S. and Canada revealed significant differences between uninsured American immigrants and Canadian immigrants, but not between insured Americans and Canadians, stratified by nativity. Findings suggest health care insurance is a critical cause of differences between immigrants and non-immigrants in access to primary care, lending robust support for the expansion of health insurance coverage in the U.S. This study also highlights the usefulness of cross-national comparisons for establishing alternative counterfactuals in studies of disparities in health and health care.     

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.     

Seeking health care: Marshallese migrants in Hawai'i

Objective. The number of Marshallese migrants has dramatically increased in the US and its territories since the 1986 Compact of Free Association agreement. Their poor health status and patterns of untimely care are considered a great public concern in the host society. This paper examines the health care patterns of Marshallese migrants in Hawai‘i and how their specific characteristics and circumstances affect their behaviors when seeking health care services.

Design. In-depth interviews were conducted with Marshallese migrants, key informants in the Marshallese community, and health and social service providers in the local community.

Results. This study reveals three important patterns of health care seeking behavior among Marshallese migrants. First, Marshallese migrants do not seek health care until they perceive a health crisis, usually indicated by pain. This cultural notion of ‘present crisis-oriented health care’ governs overall health care behaviors of Marshallese migrants. Second, Marshallese migrants are highly reliant on parochial networks for health care, given the strong mutual trust and the value assigned to interdependency within their culture. Despite many benefits of these networks, heavy dependence on them results in failure to obtain timely care when network resources become inaccessible or unavailable. Last, Marshallese migrants in Hawai‘i do not rely on traditional health care practices as much as on the allopathic health care system. Their health care depends heavily on curative and tertiary care and health care assistance in the public sector.

Conclusion. Health care seeking behaviors of migrants are shaped by cultural definition of health and health care and macro-social factors such as characteristics of the co-ethnic community and social networks, the health care system, and health policies, in addition to individual's socioeconomic status. These findings have important implications for community health care practices and policies.     

Negotiating old and new ways: contextualizing adapted health care-seeking behaviors of Korean immigrants in Hawaii

Objective. Korean immigrants have been identified as one of the most disadvantaged ethnic groups in terms of health insurance coverage and health care access in the USA. Korean immigrants enjoyed access to primary and preventive care services in their home country. This study explores how Korean immigrants' health-seeking behaviors are reconstructed by contextualizing their health care experience and adaptation process in Hawaii.

Design. Face-to-face individual in-depth interviews were conducted with 20 recently arrived Korean immigrant adults in Hawaii, who were selected by a purposive sampling method.

Results. A diminution of seeking professional health care services after immigration was the prominent change in their health care behaviors. They delayed seeking primary care, underused preventive care, extended self-diagnosis and self-treatment, and practiced more treatment- and emergency-oriented care. New immigrants also adopted ethnic enclave health care and transnational health care as alternative strategies to meet their health care needs given the structural and cultural constraints. Sociocultural contexts of both home and host countries shaped the behavioral changes and adoption of alternative health care strategies, interplaying with an individual's characteristics. Lack of health insurance and unfamiliarity with the health care system were the most important factors in the decision whether to and when to seek professional health care, while the lack of English proficiency and cultural concerns were the major determinants of where to get health care.

Conclusions. The study suggested that efforts should be concentrated to minimize structural barriers to health insurance and to improve health care access through policy interventions. Ethnic networks and ethnic media could be used as an effective informational reservoir for introducing various health care resources, disseminating information, and navigating new immigrants to the health system and services. Utilizing ethnic health care facilities and professionals would foster the promotion of immigrant health care without language and cultural challenges.     

Social networks, information and health care utilization: evidence from undocumented immigrants in Milan

This paper uses a novel dataset and research design to examine the effects of information networks on immigrants' access to health care. The dataset consists of an unusually large sample of undocumented immigrants and contains a direct indicator of information networks-whether an immigrant was referred to health care opportunities by a strong social tie (relative or friend). This measure allows to overcome some of the major identification issues that afflict most of the existing literature on network effects and to concentrate on one of the channels through which social contacts might operate. The analysis focuses on the time spent in Italy before an immigrant first receives medical assistance. Estimates indicate that networks significantly foster health care utilization: after controlling for all available individual characteristics and for ethnic heterogeneity, I find that relying on a strong social tie reduces the time to visit by 30%. The effect of information networks is stable across specifications and it is relatively large. Further investigation seems to confirm the quantitative importance of networks as an information device.     

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.     

Overcoming the Odds: Access to Care for Immigrant Children in Working Poor Families in California

Objectives: To explore the extent to which, among working poor families, uninsured immigrant children experience more barriers to care than uninsured nonimmigrants, and compare these differences to those of insured children. Methods: We used data from the 2001 California Health Interview Survey, a randomized, population-based telephone survey conducted from November 2000 through September 2001. Financial and nonfinancial access to health care and utilization of health services were examined for 3,978 nonimmigrant and 462 immigrant children and adolescents under the age of 18 years. We compared differences in crude rates across four subgroups (insured immigrants, uninsured immigrants, insured nonimmigrants, uninsured nonimmigrants) and in adjusted models controlling for socioeconomic and immigration characteristics, parental language, health status, and other demographic factors. Results: More immigrant than nonimmigrant children lacked health insurance at the time of the interview (44% vs. 17%, p < 0.0001). Among the uninsured, immigrants had higher odds of perceiving discrimination (11% vs. 5%, p < 0.05) and postponing emergency room (ER) (16% vs. 7%, p < 0.05) and dental care (40% vs. 30%, p < 0.05) after controlling for covariates. Among the insured, immigrants fared worse on almost every access and utilization outcome. Among insured immigrants, child and parent undocumented status and having a non-English-speaking parent contributed to missed physician and ER visits. Conclusions: Disparities in access and use remain for immigrant poor children despite public insurance eligibility expansions. Insurance does not guarantee equitable health care access and use for undocumented children. Financial and nonfinancial barriers to health care for immigrant children must be removed if we are to address disparities among minority children.     

"I spent nine years looking for a doctor": exploring access to health care among immigrants in Mississauga, Ontario, Canada

There is a growing body of research in Canada and from other countries acknowledging that immigrants face barriers in accessing health care services. As immigrants make up an increasing percentage of the population in many developed nations, a better understanding and eliminating these barriers is a major priority. This research contributes to current understandings of access among immigrant populations in Canada by exploring perceptions of access to care through focus groups with a diverse group of immigrants living in a Mississauga, Ontario neighbourhood. The results of eight focus groups reveal that immigrants face geographic, socio-cultural and economic barriers when attempting to access health care services in their community. This paper provides policy recommendations relevant to the federal, provincial and local levels for eliminating these barriers.     

Global Contexts,Social Capital,and Acculturative Stress: Experiences of Indian Immigrant Men in New York City

Immigrants depend on within-group social networks for social support during the acculturation process. Within-group social networks are linked to higher mutual concern and reciprocity, lower acculturative stress, and lower depression among immigrants Studies are limited, however, about immigrants’ social support in the contexts of global connectedness and transnational connectivity. Grounded in social capital approach and immigrant health framework, this qualitative, community-based study examined the social networks of immigrant men from India to New York City. Drawing upon the participants’ narratives, the author illustrates the ways that social capital influences social networking and acculturative stress in post-immigration sociocultural contexts along with its implications for community-based interventions.     

Social networks – The future for health care delivery

With the rapid growth of online social networking for health, health care systems are experiencing an inescapable increase in complexity. This is not necessarily a drawback; self-organising, adaptive networks could become central to future health care delivery. This paper considers whether social networks composed of patients and their social circles can compete with, or complement, professional networks in assembling health-related information of value for improving health and health care. Using the framework of analysis of a two-sided network – patients and providers – with multiple platforms for interaction, we argue that the structure and dynamics of such a network has implications for future health care. Patients are using social networking to access and contribute health information. Among those living with chronic illness and disability and engaging with social networks, there is considerable expertise in assessing, combining and exploiting information. Social networking is providing a new landscape for patients to assemble health information, relatively free from the constraints of traditional health care. However, health information from social networks currently complements traditional sources rather than substituting for them. Networking among health care provider organisations is enabling greater exploitation of health information for health care planning. The platforms of interaction are also changing. Patient–doctor encounters are now more permeable to influence from social networks and professional networks. Diffuse and temporary platforms of interaction enable discourse between patients and professionals, and include platforms controlled by patients. We argue that social networking has the potential to change patterns of health inequalities and access to health care, alter the stability of health care provision and lead to a reformulation of the role of health professionals. Further research is needed to understand how network structure combined with its dynamics will affect the flow of information and potentially the allocation of health care resources.     

The impact of Immigration and Customs Enforcement on immigrant health: perceptions of immigrants in Everett, Massachusetts, USA

U.S. immigrants have faced a changing landscape with regard to immigration enforcement over the last two decades. Following the passage of the Illegal Immigration Reform and Immigrant Responsibility Act of 1996, and the creation of the Immigration and Customs Enforcement (ICE) agency after the attacks of September 11, 2001, detention and deportation activity increased substantially. As a result, immigrants today are experiencing heightened fear of profiling and deportation. Little research exists on how these activities affect the health and well-being of U.S. immigrant communities. This study sought to address this gap by using community-based participatory research to investigate the impact of enhanced immigration enforcement on immigrant health in Everett, Massachusetts, USA, a city with a large and diverse immigrant population. Community partners and researchers conducted 6 focus groups with 52 immigrant participants (documented and undocumented) in five languages in May 2009. The major themes across the groups included: 1) Fear of deportation, 2) Fear of collaboration between local law enforcement and ICE and perception of arbitrariness on the part of the former and 3) Concerns about not being able to furnish documentation required to apply for insurance and for health care. Documented and undocumented immigrants reported high levels of stress due to deportation fear, which affected their emotional well-being and their access to health services. Recommendations from the focus groups included improving relationships between immigrants and local police, educating immigrants on their rights and responsibilities as residents, and holding sessions to improve civic engagement. Immigration enforcement activities and the resulting deportation fear are contextual factors that undermine trust in community institutions and social capital, with implications for health and effective integration processes. These factors should be considered by any community seeking to improve the integration process.     

Reflexiones sobre el impacto de la crisis en la salud y la atención sanitaria de la población inmigrante. Informe SESPAS 2014

Despite the economic crisis, the immigrant population of Spain continues to be high, with 5.7 million persons (11.4%). This population, whose health needs are similar to those of the general population, is more vulnerable due to their exposure to worse social determinants (living and working conditions together with a higher risk of exclusion from social services). In this article, we analyze how the economic crisis affects or can affect the health of the immigrant population in Spain by examining distinct population-specific or institutional factors that influence the effects of the crisis and the available data. The available evidence is limited, but several effects can be identified: firstly, some social determinants, such as higher unemployment rates and worse working conditions, have deteriorated, which can be expected to lead to a worsening of health status. These consequences have already been described for mental health or have been estimated for infectious diseases. Secondly, political decisions have had a direct impact, excluding–with some exceptions–undocumented immigrants from the right to health care. Finally, the lower priority given to adapting health services to the specific characteristics of the immigrant population (most of whom are documented) together with the introduction of new barriers, has hampered or will hamper access to health care. As a result, the economic crisis can be expected to have a greater impact on the immigrant population.     

Acculturating Indian Immigrant Men in New York City: Applying the Social Capital Construct to Understand Their Experiences and Health

This study qualitatively explored social capital available to individuals (N = 17) within a community-based purposive sample of adult male immigrants from India in New York City (NYC). Analysis of in-depth interview data identified possible pathways for social capital’s influences upon acculturative stress. The study defined social capital in terms of the participants’ social relationships among peers, in the workplace, and with their ethnic community. Their relationships were assessed in terms of support, trust, and reciprocity. Among the recent immigrants, hopelessness and frustration about future work prospects were associated with symptoms of depression and substance abuse. The participants identified wealth as a distinct marker of social class and they described social class as a combination of education and occupation. Social class largely determined the particular peer and community networks each participant joined. Participants relied upon ongoing connections with family in India, despite their geographic separation, to relieve acculturative stress. Social support from peers was the participants’ most useful and immediate resource for alleviating acculturative stress. For participants of lower socioeconomic status, acculturative stress was compounded by social-relationship expectations and norms from India that persisted within NYCs immigrant community. Namely, lower-SES participants were more likely to experience frustration and setbacks when they sought out intimate social relationships with women.     

Immigrant Health in Rural Maryland: A Qualitative Study of Major Barriers to Health Care Access

Immigration to rural areas in new receiving communities like Maryland’s Eastern Shore is growing. Despite a rapid rise in immigration and diminishing health system resources, little attention has been focused on barriers to health care access in this region for immigrants. A total of 33 in-depth key informant interviews with providers and immigrants were conducted. Qualitative analysis employing a constant comparison approach was used to explore emergent themes related to barriers to health care access for a growing immigrant population. Participants perceived limited health care resources, lack of health insurance coverage, high health expenditures, language barriers, and non-citizenship status as barriers to immigrants’ access of health care. Findings imply that immigrants living and working on the rural Eastern Shore face serious barriers to health care access. Additional work on immigrant health in rural areas and the impacts of immigration to rural health systems are needed.     

Immigration reform and the health of Latino immigrants in California

This paper examines Latino immigrant health within the context of the current debate over immigration reform and the resulting cultural construction of public health in California. A review of epidemiologic and ethnographic data indicates that the subordinate socioeconomic status of Latino immigrants plays a major role in both disease etiology and access to health services. However, this status does not explain why certain patterns of health services utilization and disease morbidity and mortality persist although political and economic circumstances have changed. These patterns include the reluctance to utilize certain health services despite access to health insurance and the presence of an epidemiologic paradox in which Latinos have health status indicators comparable to or better than that of other ethnic groups despite high poverty, low education, and lack of access to care. An economy of culture model is used to explain these inconsistences in the political economy model of Latino immigrant health.     

Ethnic differences in self-rated and functional health: does immigrant status matter?

The current study examines self-rated health status and functional health differences between first-generation immigrant and Canadian-born (CB) persons who share the same ethnocultural origin, and the extent to which such differences reflect social structural and health-related behavioural contexts. Multivariate analyses of data from the 2000/2001 Canadian Community Health Survey indicate that first-generation immigrants of Black and French ethnicity tend to have better health than their CB counterparts, while the opposite is true for those of South Asian and Chinese origins, providing evidence that for these groups, immigrant status matters. West Asians and Arabs and other Asian groups are advantaged in health regardless of country of birth. Health differences between ethnic foreign-born and CB persons generally converge after controlling for sociodemographic, socioeconomic status (SES), and lifestyle factors. Analysis of the data does however reveal extensive ethnocultural disparities in self-rated and functional health within both the immigrant and CB populations. Implications for health care policy and programme development are discussed.     

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.     

Contextualizing Immigrant Access to Health Resources

A vast majority of our understanding of immigrant health centers around traits of individuals and groups. While useful, current approaches to research on immigrant health decontextualize the experience of immigrants in the United States. This paper uses a historical case study of the Chinese community in San Francisco to develop a contextual framework to understand the levels of influence that impact the availability of health resources in immigrant communities. International, transnational, transcommunity, and enclave contexts have shaped health care access for Chinese immigrants in San Francisco. The conceptual framework provides a basis for future research, programmatic, and policy work that integrates individual and contextual factors in assessing and improving immigrant access to health resources.     

Community Demographics and Access to Health Care among U.S. Hispanics

Objective. To explore the influence of the communities in which Hispanics live on their access to health care.
Data. 1996–2002 Medical Expenditure Panel Survey data, linked to secondary data sources and including 14,504 observations from 8,371 Mexican American respondents living in metropolitan areas.
Study Design. We use multivariate probit regression models, stratified by individuals' insurance status, for analyses of four dependent variables measuring access to health care. We measure community characteristics at the zip code tabulation area level, and key independent variables of interest are the percentage of the population that speaks Spanish and percentage of the population that is immigrant Hispanic. Each of these measures is interacted with individual-level measures of nativity and length of U.S. residency.
Principal Findings. For Mexican American immigrants, living in an area populated by relatively more Spanish speakers or more Hispanic immigrants is associated with better access to care. The associations are generally stronger for more recent immigrants compared with those who are better established. Among U.S.-born Mexican Americans who are uninsured, living in areas more heavily populated with Spanish-speaking immigrants is negatively associated with access to care.
Conclusions. The results suggest that characteristics of the local population, including language and nativity, play an important role in access to health care among U.S. Hispanics, and point to the need for further study, including analyses of other racial and ethnic groups, using different geographic constructs for describing the local population, and, to the extent possible, more specific exploration of the mechanisms through which these characteristics may influence access to care.