Issue At A Glance: December 2018 INSTITUTE FOR HEALTH POLICY AND LEADERSHIP

Immigrant Statistics

Barriers to Healthcare Access for Immigrants in the US

The healthcare utilization rates of foreign-born residents are lower than those of native-born citizens. Immigrants’ access to healthcare can be affected by socioeconomic status, language, culture, immigration status, stigma, and location of residential settlement. Due to past healthcare reform policies, lawful immigrants cannot receive publicly funded health insurance coverage for the first five years of their residence in the United States and unauthorized migrants are permanently ineligible for these services.1

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Immigrants make up nearly 12 percent of the United States population and 17 percent of the American workforce but only account for 8.6 percent of total health care expenditures. This brief

will explore the barriers to care that immigrants commonly face in the US.

As of 2015, there were an estimated 44.7 million immigrants in the

United States.2

Approximately 75.5 percent were considered lawful immigrants. Of

those, nearly 59 percent were naturalized citizens, 35 percent

were permanent residents, and 6 percent were temporary lawful

residents.2

Less than 25 percent of immigrants in the US were undocumented

migrants.

In 2017, 53,716 refugees resettled in the United States.2

Socio-demographics of Immigrants

Overview

The US immigrant population is diverse. While 26 percent of the currently residing immigrants are from Mexico, the greatest number of new immigrants in 2016 came from India. Asians (37.1 percent) constitute a greater percentage of new immigrants than Hispanics/Latinos (31 percent).2 A majority of refugees in the US are from the Democratic Republic of Congo. Immigrants from South and East Asia, Middle East, Europe, Canada, and Sub-Saharan Africa are more likely to have a bachelor’s degree than US-born citizens, while immigrants from Mexico and Central America are less likely.2

Approximately 46 percent of immigrants live in three states: California, Texas, and New York; and 65 percent of all immigrants reside in 20 metropolitan areas.2

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INSTITUTE FOR HEALTH POLICY AND LEADERSHIP December 2018

The Epidemiological Paradox The epidemiological paradox is the concept that the children of immigrants tend to be healthier than their US-born counterparts despite their socioeconomic disadvantage or limited access to healthcare. Immigrants who arrive in the US are thought to be substantially healthier and more able to make the journey to a foreign land. This may lead to feelings of self-efficacy and positive health behaviors. Additionally, immigrants are more likely to retain their cultural and ethnic traditions and social networks that give them a protective health advantage compared to non-migrants, particularly in regard to maternal health. This may be tied to better health behaviors such as a healthier diet, more breastfeeding, and less smoking or alcohol consumption.6

Immigrants’ Healthcare Expenditures There is a common misconception that immigrants place a disproportionate burden on the healthcare and social safety-net programs. Between 2000 and 2008, the average healthcare expenditure for US-born citizens was $4,478 per capita. In comparison, the average per capita expenditure for foreign-born citizens and undocumented immigrants were $3,737 and $1,836, respectively.3

Non-citizens are less likely than naturalized immigrants and US-born immigrants to utilize the emergency department.4 Between 2000 and 2009, only 8 percent of undocumented migrants received public sector funds through emergency Medicaid; their annual expenditure for emergency services was an average of $140 per migrant. Immigrants were more likely to pay healthcare costs out-of-pocket, possibly due to the lack of coverage.5 Within their first five years of residency, low-income immigrants are four-times more likely to spend half of their household income on medical costs than other groups.3 Immigrants are also less likely to experience nonfatal occupational injuries and their average expenditures are 14 percentage points lower than ones paid for US-born workers.4

Immigrants contribute to the Medicare Health Insurance Trust Fund regardless of their documentation status. From 2002-2009, they contributed a surplus of $11-$17 billion, effectively subsidizing private insurance companies.3

Lower utilization rates drive lower expenditures.6 Two explanations account for this:

1) Immigrants, on average, are healthier than their US-born counterparts

2) Immigrants face multiple barriers to healthcare

Immigrants’ Barriers to Healthcare Access Federal policies often present the largest barrier to healthcare for immigrants. The 1996 Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA), a major immigration-related health reform policy, removed publicly-funded health insurance for lawful immigrants during the first five years of residency.1 As a result, a low-income non-citizen child was 50 percent less likely to participate in Medicaid or the Children’s Health Insurance Program (CHIP) by 2001.7

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INSTITUTE FOR HEALTH POLICY AND LEADERSHIP December 2018

In 2010, the Patient Protection and Affordable Care Act (ACA) expanded health coverage to many US citizens and long-term lawful immigrants. While the five-year ban on lawful immigrants and complete ban on unauthorized migrants still stands, the ACA increased funding for Federally Qualified Health Centers (FQHCs) which provide healthcare services to income-eligible residents regardless of documentation status.8 As of 2011, 49.9 percent of the newly arrived (less than five years of residence) immigrants were below 138 percent of the Federal Poverty Level (FPL).9 Roughly one out of every five lawfully present residents remains uninsured.6 Unauthorized immigrants are most likely to receive healthcare coverage through locally-funded programs, Children’s Health Insurance Program for unborn children (only available in some states), and emergency Medicaid.8

On an individual level, many lawful immigrants report postponing care, including prenatal visits, out of fear of being caught by immigration authorities or losing their chance to gain residency if they are deemed a public charge (a person dependent on the government for subsistence).11 On October 10, 2018, the Department of Homeland security proposed expanding the number of public programs included in the definition of public charge. As a result, family enrollment in the Supplemental Nutrition Assistance Program fell by 10 percent and immigrant households with US-born children were reported to have been turning down healthcare and other services.12

Language barriers provide another challenge to accessing care. Approximately 49 percent of immigrants are not proficient in English. In 2015, there was only one certified medical interpreter for every 2,300 patients in the state of California.13 The severe lack of medical interpreters makes communication between patients and providers difficult. The positive correlation between poor self-rated health and healthcare communication barriers can also lead to poor health outcomes.14

Cultural differences may also interfere with an immigrant’s desire to seek care. For instance, a Muslim male may not feel comfortable with a female healthcare provider. Cultural differences can lead to a sense of hierarchy and generate fear or a lack of trust between patients and providers.15 Moreover, some immigrants may not be accustomed to receiving preventive care in their native countries, leading to a lack of perceived need for certain preventive services such as vaccinations or diagnostic examinations.16

Cost and transportation can be additional barriers to accessing health care. Many immigrants often work in service industries that may not allow them to take time off. For others, especially undocumented migrants, obtaining a driver’s license can be a substantial barrier.17 Finally, many immigrants decide to forgo care due to lack of healthcare coverage and unaffordable out-of-pocket medical fees.18

Did You Know? According to the University of

Riverside Center for Innovation, more immigrants lack health

insurance in San Bernardino County (26 percent) than statewide (23

percent).10

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INSTITUTE FOR HEALTH POLICY AND LEADERSHIP December 2018

References

1. https://www.healthaffairs.org/doi/full/10.1377/hlthaff.20.1.247 2. http://www.pewresearch.org/fact-tank/2018/09/14/key-findings-about-u-s-immigrants/ 3. https://journals.sagepub.com/doi/abs/10.1177/0020731418791963?journalCode=joha 4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3779496/ 5. https://www.rand.org/pubs/research_briefs/RB9230/index1.html 6. https://www.demographic-research.org/volumes/vol25/25/25-25.pdf 7. https://www.cbpp.org/archives/4-14-03wel.htm 8. https://www.nastad.org/sites/default/files/resources/docs/Immigrant-ACA-IB-March-

2014.pdf 9. http://files.kff.org/attachment/Fact-Sheet-Health-Coverage-for-Immigrants 10. http://socialinnovation.ucr.edu/ 11. https://www.tandfonline.com/doi/full/10.1080/1369183X.2017.1323446 12. https://www.npr.org/sections/health-shots/2018/05/10/609758169/under-a-trump-

proposal-lawful-immigrants-might-shun-medical-care 13. http://centerforhealthreporting.org/article/medical-interpreters-short-supply-health-

coverage-grows 14. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4930414/ 15. https://pxjournal.org/cgi/viewcontent.cgi?article=1181&context=journal 16. https://www.sciencedirect.com/science/article/pii/S1877042814032200 17. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5930513/ 18. https://journalofethics.ama-assn.org/article/culture-within-culture-us-immigrants-

confront-health-system-many-citizens-cant-manage/2005-07 19. https://www.scph.org/sites/default/files/editor/Immigrant-Health-in-the-US.pdf

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Questions? Please contact Priya Vedula, MPH Health Policy Analyst at the Institute for Health Policy & Leadership (pvedula@llu.edu)

Ongoing Challenges The health of immigrants is largely shaped by a number of factors: the socio-political conditions of the native land, the immigration experience, assimilation and acculturation, marginalization, and language barriers. Immigrants face additional stress associated with the resettlement process in a new country. Moreover, there is a chronic fear of deportation and family separation.19 Over time, these stressors can contribute to health disparities and increase the morbidity and mortality associated with chronic diseases.

As 17 percent of the workforce, immigrants are a vital part of the American economy and contribute to the sustainability of our public and private health insurance markets.1,3 Ensuring good health outcomes will continue to be a pressing health policy challenge for the United States.

Did You Know?

Certain diseases disproportionately affect immigrant groups. For

instance, 61 percent of Hispanic/Latino individuals

diagnosed with HIV/AIDs were foreign-born in 2011. Data also

indicates that approximately 54,000 immigrants who come to the US

every year have hepatitis B.8