Immigrants and the Affordable Care Act: Changes in Coverage and Access to Care by Documentation Status

Supporting organizations to improve migrants' access to health services in New York City

Purpose

To survey community-based migrant-serving organizations (MSOs) in New York City (NYC) regarding their early experiences during the COVID-19 pandemic and perspectives on academic collaborations.

Methods

We developed and emailed a survey via Qualtrics (12/2020-1/2021) to 122 MSOs in NYC collecting data about the organizations; challenges posed by COVID-19; and interest in potential intersectoral collaboration. Descriptive analysis focused on the pandemic's impact on service provision, type of MSO, and organizational capacity.

Results

Thirty-eight MSOs participated (RR=31%). COVID-19-related challenges included limited staff capacity, organizational funding, and technological and resource limitations of communities served. Organizational capacity correlated with types of services offered: smaller organizations offered health and social services, while larger organizations focused on education and employment. MSOs indicated interest in collaboration on migrant policy advocacy and communications, access to interns, and resources regarding best practices and policies.

Conclusions

MSOs in NYC have struggled with funding, staffing, and service provision. They specified fruitful areas for collaboration with academic research institutions.

Implications

Development of an academic-based migrant health resource hub will serve an identified need among MSOs in NYC.

Comparing the health of refugee and asylee patients with that of non-refugee immigrant and US-born patients in a large Urban clinic

OBJECTIVES

To compare disease burden in refugee/asylee, non-refugee immigrant, and US-born patients in the largest safety net clinic in San Francisco, California.

METHODS

This is a retrospective chart review including 343 refugee/asylee, 450 immigrant, and 202 US-born patients in a San Francisco clinic from January 2014 to December 2017. Using electronic medical records, we compared prevalence of several diseases by immigration status. Using Poisson regression models with robust variance, we assessed association of diseases with immigration status, adjusting for sociodemographic characteristics.

RESULTS

Diagnoses of non-communicable chronic diseases were less common in refugees/asylees, who had a greater risk of being diagnosed with mental health conditions. In Poisson regression models adjusted for sociodemographic characteristics, compared with refugees/asylees, US-born patients were more likely to have hypertension (IRR[CI] = 1.8 [1.0, 3.7]) and less likely to have depression (IRR[CI] = 0.5 [0.3, 0.8]). US-born (IRR[CI] = 0.06 [0.01, 0.2]) and immigrant patients (IRR[CI] = 0.1 [0.06, 0.2]) were less likely to have post-traumatic stress disorder.

CONCLUSIONS

We uncover differences in burden of non-communicable chronic diseases and mental health by immigration status. These results highlight the importance of clinical screenings and research on disease burden in refugees.

State Public Insurance Coverage Policies and Postpartum Care Among Immigrants

Importance

Professional medical organizations recommend that adults receive routine postpartum care. Yet, some states restrict public insurance coverage for undocumented immigrants and recently documented immigrants (those who received legal documentation status within the past 5 years).

Objective

To examine the association between public insurance coverage and postpartum care among low-income immigrants and the difference in receipt of postpartum care among immigrants relative to nonimmigrants.

Design, Setting, and Participants

A pooled, cross-sectional analysis was conducted using data from the Pregnancy Risk Assessment Monitoring System for 19 states and New York City including low-income adults with a live birth between 2012 and 2019.

Exposure

Giving birth in a state that offered public insurance coverage for postpartum care to recently documented or undocumented immigrants.

Main Outcomes and Measures

Self-reported receipt of postpartum care by the category of coverage offered (full coverage: states that offered publicly funded postpartum care regardless of immigration status; moderate coverage: states that offered publicly funded postpartum care to lawfully residing immigrants without a 5-year waiting period, but did not offer postpartum care to undocumented immigrants; no coverage: states that did not offer publicly funded postpartum care to lawfully present immigrants before 5 years of legal residence or to undocumented immigrants).

Results

The study included 72 981 low-income adults (20 971 immigrants [29%] and 52 010 nonimmigrants [71%]). Of the 19 included states and New York City, 6 offered full coverage, 9 offered moderate coverage, and 4 offered no coverage; 1 state (Oregon) switched from offering moderate coverage to offering full coverage. Compared with the states that offered full coverage, receipt of postpartum care among immigrants was 7.0-percentage-points lower (95% CI, -10.6 to -3.4 percentage points) in the states that offered moderate coverage and 11.3-percentage-points lower (95% CI, -13.9 to -8.8 percentage points) in the states that offered no coverage. The differences in the receipt of postpartum care among immigrants relative to nonimmigrants were also associated with the coverage categories. Compared with the states that offered full coverage, there was a 3.3-percentage-point larger difference (95% CI, -5.3 to -1.4 percentage points) in the states that offered moderate coverage and a 7.7-percentage-point larger difference (95% CI, -10.3 to -5.0 percentage points) in the states that offered no coverage.

Conclusions and Relevance

Compared with states without insurance restrictions, immigrants living in states with public insurance restrictions were less likely to receive postpartum care. Restricting public insurance coverage may be an important policy-driven barrier to receipt of recommended pregnancy care and improved maternal health among immigrants.

Chilling Effects on Immigrants' Health Insurance Coverage After the 2016 Presidential Election

BACKGROUND

Depressed enrollment in public benefits among immigrants and their families may occur due to concerns about deportation and obstacles to permanent residency status related to immigration policies.

METHODS

Using data from the American Community Survey (ACS) from 2014 to 2019, we conducted an interrupted time series analysis to estimate Medicaid enrollment, private insurance enrollment, and uninsured rates among low-income non-citizen adults and their children, compared to U.S. citizens before and after the Trump administration entered office in January 2017.

RESULTS

Compared to U.S. citizen adults, Medicaid enrollment among non-citizen adults decreased and the uninsured rate increased (1.5 percentage points per year, p < 0.05) from 2017 to 2019. Decreases in coverage starting in 2017 were larger among both children with at least one non-citizen parent and non-citizen children.

DISCUSSION

These findings suggest that the Trump administration immigration policy climate is associated with decreased health insurance enrollment among this population.

Housing Insecurity Among Latinxs

Latinxs are vulnerable to experiencing housing insecurity and less likely to receive public benefits, such as health insurance, which can impact a household's economic resources. We inform homelessness prevention by examining the association of social risks and healthcare access with housing insecurity for Latinxs. Our sample consisted of 120,362 participants under the age of 65, of which 17.3% were Latinx. Weighted chi-squared tests and logistic regression were used to examine predictors of housing insecurity. Housing insecurity was measured as worry about paying for housing. Latinxs were almost twice as likely as non-Latinxs to worry about paying for housing. Excellent/fair health status, health service use, and having health insurance decreased the likelihood of housing insecurity for Latinxs. Access to health insurance, regardless of citizenship status, and use of preventative healthcare to maintain good health can be protective against housing insecurity.

Another Brick in the Wall: Healthcare Access Difficulties and Their Implications for Undocumented Latino/a Immigrants

The mounting evidence highlighting the disproportionate impact of the COVID-19 pandemic in ethnic minority communities underscores the need to understand how distress and healthcare access impacts the well-being of undocumented Latino/a immigrants (ULIs), one of the most marginalized and vulnerable ethnic minority communities in the U.S. We used existing data from a cross sectional study (Proyecto Voces) of 252 ULIs to conduct path analyses that explored the relations among distress due to immigration legal status, healthcare access difficulties, and the health of ULIs. Results demonstrated that distress due to immigration legal status is related to the physical and mental health of ULIs, and that difficulties in accessing healthcare explained these relations. These data support the importance of immediate, targeted efforts for increasing access to healthcare among undocumented immigrants and highlight the long-term importance of a much-needed healthcare reform for improving access to marginalized populations.