Welfare reform and health insurance of immigrants

The "disproportionate costs" of immigrant policy on the health of Latinx and Asian immigrants

There is growing evidence that Asian and Latinx immigrants' health and health care access is shaped by immigrant policies that determine their rights, protections, and access to resources and the extent to which they are targeted by policing or deportation based on citizenship/legal status and other immigration-related social categories. However, there is limited population-based evidence of how immigrants experience the direct consequences of policies, nor of the impact of such consequences on their health. Between 2018 and 2020, we conducted the Research on Immigrant Health and State Policy (RIGHTS) Study, developing a population-based survey of Asian and Latinx immigrants in California (n = 2010) that measured 23 exclusionary experiences under health care and social services, education, labor/employment, and immigration enforcement policies. Applying Ruth Wilson Gilmore's concept of "disproportionate costs," we conducted a latent class analysis (LCA) and regression models of the RIGHTS data to 1) describe patterns of immigrant policy exclusion experienced by Asian and Latinx immigrants and 2) test relationships between patterns of policy exclusion and health care access and health status. LCA analyses identified 6 classes of distinct combinations of policy exclusions. In regression analyses, respondents in the class with cumulative exclusions across all policy sectors had the worst health care access and highest level of psychological distress, but the best self-rated health; while those in the class with employment and enforcement exclusions also had poor health care access. Respondents in the other 3 classes experienced combinations of health and social services exclusions, but these alone were not associated with worse outcomes. Findings show that the consequences of immigrant policies harm health through both cumulative exposure to and intersections of exclusions across policy sectors. Labor/employment and immigration enforcement policies, specifically, likely drive health inequities within immigrant populations. The RIGHTS study highlights the need to measure the cumulative and intersecting "disproportionate costs" of immigrant policy within diverse immigrant populations.

The Impact of China's Family Floating Population on the Participation of Medical Insurance in the Inflow Areas

Background

With the transformation of China's economy and society, the floating population has also shown a new development trend, from individual migration to co-migration with family members. In 2020, among the 376 million floating population, the population flowing to cities and towns was 330 million, accounting for nearly 88.1%. The family mobility of the floating population is not just a simple personal gathering or geographical migration, but a profound adjustment of the living environment, social interaction and the interests of family members. Migrants no longer simply play the role of " urban passers-by", but gradually move with spouses, children, parents, and even settle in the city, which will inevitably produce different public service and social security needs.

Objective

To explore the impact of floating population's familyization on the participation of medical insurance in the inflow areas.

Methods

This study adopted the form of non-systematic literature review. The key words were floating population and medical insurance. The related analysis of PubMed, Embase, CNKI, Wanfang, and VIP databases were reviewed and summarized.

Results

Due to the flow between domestic immigrants and regions, their medical insurance is difficult to be guaranteed. The domestic floating population's demand for health services is increasing, but the coverage of medical services provided by medical insurance is not comprehensive enough.

Conclusion

It is necessary to integrate the medical insurance system and improve the adaptability of medical insurance to family mobility; protect the welfare needs of migrant families and increase their willingness to participate in medical insurance at the destination; pay attention to the interaction and integration of floating population families, understand and guide them to participate in the status quo of medical insurance, and improve the status quo.

Hitting closer to home: State policies' impacts on health by race and legal status

While the proliferation of inclusionary and exclusionary state policies has led to an increasingly heterogeneous patchwork of state climates, state policy and the climates they create have become increasingly important for health outcomes. We leverage the heterogeneity across state policy climates to test the relationship between state-level policies and health inequality across the US. We include 24 state policies related to public health and safety, immigration enforcement, integration, and healthcare to capture the state climate. Using the Survey of Income and Program Participation (SIPP), a nationally representative study of households in the U.S., we estimate multilevel regression models to assess the relationship between state policy climate and healthcare utilization. We further examine differential effects of the policy climate across various vulnerable groups, by examining differences by citizenship status and race. We find that more exclusionary policies may be detrimental to healthcare utilization for all residents regardless of race and legal status- but ultimately racial minorities and noncitizens see the greatest benefits from inclusive policy climates.

Predicted Health Literacy Disparities Between Immigrant and US-Born Racial/Ethnic Minorities: a Nationwide Study

BACKGROUND

Racial/ethnic minorities in the USA exhibit reduced health literacy (HL) proficiency, leading to increased health disparities. It is unclear how the effect of birth status (immigrant/US-born) affects HL proficiency among racial/ethnic minorities.

OBJECTIVE

To identify the direct, indirect, and total effects of birth status on HL proficiency among a nationally representative population of racial/ethnic minority adults in the USA.

DESIGN

A cross-sectional study of 2019 data from the Medial Expenditure Panel Survey.

PARTICIPANTS

Participants aged 18 or older reporting as racial/ethnic minorities (Black, Asian, or Hispanic) with non-missing data.

MAIN MEASURES

We predicted HL proficiency for each participant using a previously published model. Path analysis was used to estimate the direct, indirect, and total effects of birth status on HL proficiency, accounting for several other covariates. Prevalence ratios were estimated using adjusted Poisson regression to evaluate differences in the "Below Basic" HL category.

KEY RESULTS

An estimated weighted 81,092,505 participants were included (57.5% US-born, 42.5% immigrant). More racial/ethnic minority immigrant participants fell into the lowest category of HL proficiency, "Below Basic" (14.3% vs 5.5%, p < 0.05). Results of the path analysis indicated a significant, negative direct effect of birth status on HL proficiency (standardized coefficient = - 0.24, SE = 0.01, 95%CI: - 0.26, - 0.23) in addition to an indirect effect mediated through insurance status, health-system resource use, and English proficiency. The total effect of birth status on HL proficiency was found to be - 0.29. The immigrant participant group had 81% higher prevalence of falling into the "Below Basic" HL category compared to US-born participants (prevalence ratio = 1.81, 95%CI: 1.52, 2.16).

CONCLUSIONS

Immigrant status has a strong, negative, direct effect on HL proficiency among racial/ethnic minorities in the USA. This may be a result of barriers that prevent equitable access to resources that improve proper HL proficiency. US policymakers may consider several methods to reduce this disparity at the health-system-, provider-, and patient-levels.

Reduced health care utilization among young children of immigrants after Donald Trump's election and proposed public charge rule

Widespread fear among immigrants from hostile 2016 presidential campaign rhetoric decreased social and health care service enrollment (chilling effect). Health care utilization effects among immigrant families with young children are unknown. We examined whether former President Trump's election had chilling effects on well-child visit (WCV) schedule adherence, hospitalizations, and emergency department (ED) visits among children of immigrant vs US-born mothers in 3 US cities. Cross-sectional surveys of children <4 years receiving care in hospitals were linked to 2015-2018 electronic health records. We applied difference-in-difference analysis with a 12-month pre/post-election study period. Trump's election was associated with a 5-percentage-point decrease (-0.05; 95% CI: -0.08, -0.02) in WCV adherence for children of immigrant vs US-born mothers with no difference in hospitalizations or ED visits. Secondary analyses extending the treatment period to a leaked draft of proposed changes to public charge rules also showed significantly decreased WCV adherence among children of immigrant vs US-born mothers. Findings indicate likely missed opportunities for American Academy of Pediatrics-recommended early childhood vaccinations, health and developmental screenings, and family support. Policies and rhetoric promoting immigrant inclusion create a more just and equitable society for all US children.

Engagement in the Michigan Screening and Intervention for Glaucoma and Eye Health through Telemedicine Program: Comparing the Effect of Clinic versus Community-Based Recruitment Strategies

PURPOSE

To determine the effectiveness of adding community-based recruitment to clinic-based recruitment to engage participants in a glaucoma detection program.

DESIGN

Prospective cohort study.

SUBJECTS

Anyone ≥ 18 years of age who does not meet exclusion criteria.

METHODS

The Michigan Screening and Intervention for Glaucoma and Eye Health through Telemedicine (MI-SIGHT) program tests a novel way of improving glaucoma detection in communities with populations at high risk for disease, including people who identify as Black and Hispanic and those living with low socioeconomic status. The MI-SIGHT program is conducted in a free clinic (Ypsilanti, MI) and in a federally qualified health center (FQHC) (Flint, MI). Community engagement methods were used to identify outreach strategies to enhance recruitment. Participants were asked "How did you hear about the MI-SIGHT program?" and responses were summarized overall and by clinic and compared between clinic-based and community-based recruitment strategies.

MAIN OUTCOME MEASURES

Proportion recruited by location, within or outside of the clinic.

RESULTS

In total, 647 participants were recruited in the first 11 months of the study, 356 (55.0%) at the free clinic over 11 months and 291 (45.0%) at the FQHC over 6 months. Participants were on average 54.4 years old (standard deviation = 14.2); 60.9% identified as female, 45.6% identified as Black, 37.8% identified as White, 9.6% identified as Hispanic, and 10.9% had less than high school education. Participants reported hearing about the MI-SIGHT program from a clinic phone call (n = 168, 26.1%), a friend (n = 112, 17.4%), nonmedical clinic staff (n = 100, 15.5%), a clinic doctor (n = 77, 11.9%), an in-clinic brochure or flyer (n = 51, 7.9%), a community flyer (n = 44, 6.8%), the clinic website or social media (n = 28, 4.3%), or an "other" source (n = 65, 10.1%). Recruiting from the community outside the medical clinics increased participation by 265% at the free clinic and 46% at the FQHC.

CONCLUSIONS

The Community Advisory Board recommendation to use community-based recruitment strategies in addition to clinic-based strategies for recruitment resulted in increased program participation.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Effects of the Children's Health Insurance Reauthorization Act on immigrant children's healthcare access

OBJECTIVE

To estimate the effects of Children's Health Insurance Reauthorization Act (CHIPRA), a policy that provided states the option to extend Medicaid/CHIP eligibility to immigrant children who have not been legal residents for five years or more, on insurance coverage, access, utilization, and health outcomes among immigrant children.

DATA SOURCES

Restricted use 2000-2016 National Health Interview Survey (NHIS).

STUDY DESIGN

We used a difference-in-differences design that compared changes in CHIPRA expansion states to changes in non-expansion states.

DATA COLLECTION

Our sample included immigrant children who were born outside the US, aged 0-18 with family income below 300% of the Federal Poverty Level (FPL). Subgroup analyses were conducted across states that did and did not have a similar state-funded option prior to CHIPRA (state-funded vs. not state-funded), by the length of time in the US (5 years vs. 5-14 years), and global region of birth (Latin American vs. Asian countries).

PRINCIPLE FINDINGS

We found that CHIPRA was associated with a significant 6.35 percentage point decrease in uninsured rates (95% CI: -11.25, -1.45) and an 8.1 percentage point increase in public insurance enrollment for immigrant children (95% CI: 1.26, 14.98). However, the effects of CHIPRA became small and statistically not significant 3 years after adoption. Effects on public insurance coverage were significant in states without state-funded programs prior to CHIPRA (15.50 percentage points; 95% CI:8.05, 22.95) and for children born in Asian countries (12.80 percentage points; 95% CI: 1.04, 24.56). We found no significant changes in health care access and utilization, and health outcomes, overall and across subgroups due to CHIPRA.

CONCLUSIONS

CHIPRA's eligibility expansion was associated with increases in public insurance coverage for low-income children, especially in states where CHIPRA represented a new source of coverage versus a substitute for state-funded coverage. However, we found evidence of crowd-out in certain subgroups and no effect of CHIPRA on access to care and health. Our results suggest that public coverage may be an important tool for promoting the well-being of immigrant children but other investments are still needed.

Systems of Oppression: The Impact of Discrimination on Latinx Immigrant Adolescents' Well-Being and Development

With over 400 harmful immigration policy changes in the past 4 years, Latinx adolescents and families nationwide are developing within a context of extreme anti-immigrant sentiment (Dismantling and reconstructing the U.S. immigration system: A catalog of changes under the Trump presidency, Migration Policy Institute, 2020). This paper introduces the Multitiered Model of Oppression and Discrimination (MMOD), a conceptual model for understanding the impacts of multiple levels of discrimination on the well-being and development of Latinx immigrant adolescents. Interpersonal discrimination (Hispanic Journal of Behavioral Sciences, 2010, 32, 259), community-held stereotypes (Social Psychology of Education, 2001, 5, 201), institutional policies (Children and Youth Services Review, 2018, 87, 192), and structural practices (Journal of Criminal Justice, 2020, 66, 1) can negatively impact well-being and development among these adolescents. Culturally sustaining interventions, civic engagement and mobilization, and policies targeting inequitable policies and practices will provide healing and an avenue for liberation.

Do state laws reduce uptake of Medicaid/CHIP by U.S. citizen children in immigrant families: evaluating evidence for a chilling effect

Background

Restrictive state laws aimed at immigrants can have unintended consequences for health insurance coverage of United States citizens in immigrant families due to both actual barriers created by the laws and perceived barriers among immigrants. Increasing numbers of children in the U.S. are part of immigrant families, and these children are more likely to be living in poverty than their counterparts in native families. Immigrant restrictive policies could lead to reduced access to Medicaid and CHIP even for citizen children in immigrant families.

Methods

Using data from the Current Population Survey's (CPS) March Supplement, linear probability models with difference-in-differences (DD) estimates compare probability of enrollment in Medicaid/CHIP among low-income U.S. citizen children in immigrant families and low-income children in native families and U.S. citizen children in immigrant families in states that did not adopt restrictive legislation, in order to estimate the impact of restrictive state laws aimed at immigrants. An additional model explores the effect of mother’s citizenship on enrollment among all immigrant families in states with and without restrictive legislation.

Results

Results suggest a significant chilling effect where the magnitude of the effect varies according to family demographics and by the types of laws being passed. Immigrant restrictive social welfare laws being adopted have a strong negative effect on U.S. citizen children in immigrant families’ enrollment in Medicaid/CHIP, a 5.5 percentage point reduction in coverage. Among the subsample of only immigrant families, results point toward a global chilling effect created by an overall restrictive policy environment. All immigrant restrictive related laws, including those aimed at education, job restriction, identification access, and social welfare restrictions have a significant and negative impact on access to public insurance for U.S. citizen children with non-citizen mothers.

Conclusions

This research shows that the unintended consequence of restrictive state legislation aimed at immigrants is the reduction in access to Medicaid and CHIP by low-income U.S. citizen children living in immigrant families. Reduced access to health insurance can increase unmet medical needs for an already vulnerable group.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12939-022-01651-2.

Correlates of Undiagnosed Hypertension Among Chinese and Korean American Immigrants

Asian Americans are more likely to be unaware that they have hypertension compared to non-Hispanic white Americans, despite having higher risk of hypertension at lower body-mass indices. Furthermore, immigrants are more likely than their United States (U.S.)-born counterparts to have undiagnosed hypertension, placing them at greater risk of subsequent morbidity and mortality. This study examines the social determinants of undiagnosed hypertension among Asian American immigrants. Using a study of foreign-born Chinese and Korean Americans between the ages of 50-75 years-old recruited from physicians' clinics in the Baltimore-Washington DC Metropolitan Area (n = 355), we used blood pressure readings measured by trained staff members, self-reported diagnosis by a medical professional, and self-reported hypertension medication use to determine hypertension status-whether patients were non-hypertensive, had diagnosed hypertension, or had undiagnosed hypertension. Using multinomial logistic regression, we examined how demographic, socioeconomic, and immigration-related factors were associated with hypertension status. Results indicated that older age, male gender, Korean subgroup, and marital status were associated with having diagnosed hypertension compared to being non-hypertensive. Lack of health insurance was the strongest predictor of having undiagnosed hypertension compared to being non-hypertensive. Acculturation variables had no strong associations with hypertension status. We then explored correlates of health insurance status for Chinese and Korean American immigrants. Those without health insurance were more likely to have lower income and to be not currently employed. Our findings point to the importance of increasing health insurance access for Asian American immigrant groups to ensure that hypertension is not left undiagnosed and untreated.

Chilling Effects: US Immigration Enforcement And Health Care Seeking Among Hispanic Adults

Aggressive deportation policy enforcement in the US may make undocumented immigrants and those close to them reluctant to seek medical care. With 68 percent of undocumented immigrants coming from Mexico or Central America, US deportation policies particularly affect Hispanic residents. To examine how deportation enforcement relates to health care use in the Hispanic population in general, we matched survey data from the 2011-16 Behavioral Risk Factor Surveillance System to measures of Immigration and Customs Enforcement (ICE) activity. Quasi-experimental analyses demonstrated that Hispanic respondents were less likely to report having had a regular provider or annual checkup following increased ICE activity in their state. In contrast, these behaviors were unchanged among non-Hispanic adults, a group less likely to be affected by deportation enforcement. Parallel results were found among Hispanic and non-Hispanic adults with diabetes, for whom lapses in care may confer significant health risks.

Quantifying direct effects of social determinants of health on systolic blood pressure in United States adult immigrants

Identify the pathway by which social determinants of health (SDoH) variables impact systolic blood pressure (SBP) in immigrants. Latent variables were used to assess the relationship between SDoH and SBP. Latent variables were identified using confirmatory factor analysis (CFA) for (1) global socioeconomic status (SES) (education, income, number of hours worked per week), (2) stressors of immigration (life-course SES, immigration stress, immigration demand), (3) adaptation to immigration (perceived discrimination, perceived stress, health literacy), and (4) burden of disease (disability, comorbidities, chronic pain). Structural equation modeling (SEM) was used to investigate the relationship between immigrant specific latent variables and SBP. The study included 181 adult immigrants. The initial model (chi2 (77, n = 181) = 302.40, p < 0.001, RMSEA = 0.086, CFI = 0.84, TLI = 0.78, CD = 0.91) showed that stressors of immigration had a direct relationship with SBP (-0.35, p = 0.033); global (SES) had a direct relationship with burden of disease (-0.70, p = 0.007) and an indirect relationship with SBP by way of burden of disease (0.24, p = 0.015). The final model (chi2 (69, n = 181) = 149.98, p < 0.001, RMSEA = 0.054, CFI = 0.94, TLI = 0.91, CD = 0.96) maintained that global SES had a direct relationship with burden of disease (-0.40, p < 0.001) and an indirect relationship with SBP by way burden of disease (0.34, p < 0.001). This study suggests a direct relationship between burden of disease and SBP, and an indirect relationship between SES and SBP. Development of interventions should take burden of disease into account as a direct driver of blood pressure in immigrants, and address factors related to SES.

Impact of medicaid policy changes on immigrant parents

During the 1990s and early 2000s many states expanded Medicaid eligibility for parents particularly after the 1996 welfare reform. At the same time, welfare reform also put in place policies that limited the eligibility of recent immigrants for public programs including Medicaid. This paper evaluates the effects of these changes in Medicaid eligibility policy on the private and public health insurance coverage of immigrants as well as the overall insurance rate. It also looks at the effect on health care use and measures of health status. The findings indicate a significant increase in Medicaid coverage and an increase in the proportion insured overall with negligible crowd-out of private insurance. There is also an increase in the use of health care services. In the case of permanent residents, there is a diminished response to Medicaid eligibility changes possibly due to a "chilling effect".

Restrictive state laws aimed at immigrants: Effects on enrollment in the food stamp program by U.S. citizen children in immigrant families

This paper examines whether a chilling effect of restrictive state laws aimed at immigrants creates a barrier to enrollment in the food stamp program (now called the Supplemental Nutrition Assistance Program or SNAP) for U.S. citizen children in low-income immigrant families. This analysis looks at 20 states in the continental United States from 2000 to 2008 that were either at or above the U.S. average for percentage of foreign-born population, or states that ranked in the top 10 percent in terms of change in foreign-born population for that time period. To examine this issue, a multivariate, regression-based difference-in-differences (DD) analysis was applied. The "treatment" group is immigrant families with a U.S. citizen child that is 130% of the federal poverty level or below in states with restrictive immigrant related legislation and the "control" group is native families meeting the same federal poverty level guidelines as well as low-income immigrant families in states without the restrictive legislation. The research findings show that there does not appear to be a chilling effect associated with restrictive state laws on participation in the food stamp program. Food insecurity is an immediate need that may override the impediments to enrollment due to immigration status, causing families to apply despite a negative climate toward immigrants. For policy makers and immigrant advocates it is important to know where chilling effects might not occur in order to work with politicians and federal agencies on crafting sound evidence-based policy. Independent of any chilling effect, the model shows that immigrant families are less likely to enroll in food stamp benefits, consistent with other literature. In addition, independent of the effects of restrictive immigration legislation, both non-citizen and naturalized mothers were less likely to be in a family with food stamp benefits compared to similar native-born mothers. This indicates that all states have a gap in food stamp program enrollment that merits further attention and research.

Policies of Exclusion: Implications for the Health of Immigrants and Their Children

Public policies play a crucial role in shaping how immigrants adapt to life in the United States. Federal, state, and local laws and administrative practices impact immigrants' access to education, health insurance and medical care, cash assistance, food assistance, and other vital services. Additionally, immigration enforcement activities have substantial effects on immigrants' health and participation in public programs, as well as effects on immigrants' families. This review summarizes the growing literature on the consequences of public policies for immigrants' health. Some policies are inclusive and promote immigrants' adaptation to the United States, whereas other policies are exclusionary and restrict immigrants' access to public programs as well as educational and economic opportunities. We explore the strategies that researchers have employed to tease out these effects, the methodological challenges of undertaking such studies, their varying impacts on immigrant health, and steps that can be undertaken to improve the health of immigrants and their families.

Effects of non-health-targeted policies on migrant health: a systematic review and meta-analysis

BACKGROUND

Government policies can strongly influence migrants' health. Using a Health in All Policies approach, we systematically reviewed evidence on the impact of public policies outside of the health-care system on migrant health.

METHODS

We searched the PubMed, Embase, and Web of Science databases from Jan 1, 2000, to Sept 1, 2017, for quantitative studies comparing the health effects of non-health-targeted public policies on migrants with those on a relevant comparison population. We searched for articles written in English, Swedish, Danish, Norwegian, Finnish, French, Spanish, or Portuguese. Qualitative studies and grey literature were excluded. We evaluated policy effects by migration stage (entry, integration, and exit) and by health outcome using narrative synthesis (all included studies) and random-effects meta-analysis (all studies whose results were amenable to statistical pooling). We summarised meta-analysis outcomes as standardised mean difference (SMD, 95% CI) or odds ratio (OR, 95% CI). To assess certainty, we created tables containing a summary of the findings according to the Grading of Recommendations Assessment, Development, and Evaluation. Our study was registered with PROSPERO, number CRD42017076104.

FINDINGS

We identified 43 243 potentially eligible records. 46 articles were narratively synthesised and 19 contributed to the meta-analysis. All studies were published in high-income countries and examined policies of entry (nine articles) and integration (37 articles). Restrictive entry policies (eg, temporary visa status, detention) were associated with poor mental health (SMD 0·44, 95% CI 0·13-0·75; I2=92·1%). In the integration phase, restrictive policies in general, and specifically regarding welfare eligibility and documentation requirements, were found to increase odds of poor self-rated health (OR 1·67, 95% CI 1·35-1·98; I2=82·0%) and mortality (1·38, 1·10-1·65; I2=98·9%). Restricted eligibility for welfare support decreased the odds of general health-care service use (0·92, 0·85-0·98; I2=0·0%), but did not reduce public health insurance coverage (0·89, 0·71-1·07; I2=99·4%), nor markedly affect proportions of people without health insurance (1·06, 0·90-1·21; I2=54·9%).

INTERPRETATION

Restrictive entry and integration policies are linked to poor migrant health outcomes in high-income countries. Efforts to improve the health of migrants would benefit from adopting a Health in All Policies perspective.

FUNDING

Swedish Council for Health, Working Life, and Social Research; UK Medical Research Council; Scottish Government Chief Scientist Office.

Awareness of High Blood Pressure by Nativity Among Black Men: Implications for Interpreting the Immigrant Health Paradox

Introduction

Differences in the social determinants of health and cardiovascular health outcomes by nativity have implications for understanding the immigrant health paradox among black immigrants. We aimed to understand whether blood pressure awareness, a precursor to achieving blood pressure control among hypertensive patients, varied by nativity among a sample of black men.

Methods

Data were collected from 2010 through 2014. In 2016, we conducted logistic regression models using data from a large sample of urban-dwelling middle-aged and older black men. All men in the study had measured high blood pressure at the time of enrollment and were also asked whether they were aware of having high blood pressure. Independent variables included demographics, socioeconomic status, access to care, and health-related behaviors.

Results

Foreign-born participants were significantly less likely than US-born participants to report awareness of having high blood pressure (P < .001). We observed a significant positive relationship between proportion of life spent in the US and being aware of having hypertension (β = 0.863; 95% CI, 0.412–1.314; P < .001). This relationship remained after adjusting the model for salient independent variables (β = 0.337; 95% CI, 0.041–0.634; P = .03).

Conclusions

Difference in hypertension awareness by nativity may skew surveillance estimates used to track health disparities by large heterogeneous racial categories. Our results also indicate that prior health care experience and circumstances should be considered when studying the immigrant health paradox.

State-level immigration and immigrant-focused policies as drivers of Latino health disparities in the United States

There has been a great deal of state-level legislative activity focused on immigration and immigrants over the past decade in the United States. Some policies aim to improve access to education, transportation, benefits, and additional services while others constrain such access. From a social determinants of health perspective, social and economic policies are intrinsically health policies, but research on the relationship between state-level immigration-related policies and Latino health remains scarce. This paper summarizes the existing evidence about the range of state-level immigration policies that affect Latino health, indicates conceptually plausible but under-explored relationships between policy domains and Latino health, traces the mechanisms through which immigration policies might shape Latino health, and points to key areas for future research. We examined peer-reviewed publications from 1986 to 2016 and assessed 838 based on inclusion criteria; 40 were included for final review. These 40 articles identified four pathways through which state-level immigration policies may influence Latino health: through stress related to structural racism; by affecting access to beneficial social institutions, particularly education; by affecting access to healthcare and related services; and through constraining access to material conditions such as food, wages, working conditions, and housing. Our review demonstrates that the field of immigration policy and health is currently dominated by a "one-policy, one-level, one-outcome" approach. We argue that pursuing multi-sectoral, multi-level, and multi-outcome research will strengthen and advance the existing evidence base on immigration policy and Latino health.

Legal Status, Time in the USA, and the Well-Being of Latinos in Los Angeles

In the USA, undocumented Latino immigrants may have poorer health because of barriers to health care, stressors, and detrimental effects of immigration enforcement. Previous immigrant health research, however, suggests that recently arrived Latino immigrants have better health than US-born Latinos and their health deteriorates over time. Given the current environments that undocumented immigrants face, legal status is a structural factor that likely influences the patterns of immigrant health. Therefore, the aim of this study was to examine the extent to which physical and mental health differed by legal status and duration in the USA for the Latino population in Los Angeles County, California. We conducted analysis of Latino respondents (n = 1396) to the Los Angeles Family and Neighborhood Survey (L.A.FANS) Wave II. We examined self-reported health, depression measured by the Composite International Diagnostic Interview-Short Form, and blood pressure collected by trained interviewers. Respondents reported their legal status, time in the USA, and other sociodemographic characteristics. Regression models were used to test associations between each outcome and 1) legal status and 2) legal status by duration (≤ 15 and > 15 years) in the USA. Without taking duration into account, we found no significant differences in outcomes between undocumented, documented, or US-born Latinos. Taking duration into account, shorter duration undocumented immigrants had worse self-reported health than the US born. Undocumented immigrants, regardless of duration, had higher blood pressure than documented immigrants who had been in the USA for less time and the same level of blood pressure as the US born. In contrast, shorter duration documented immigrants had lower blood pressure compared to longer duration documented immigrants and US-born counterparts, and marginally lower blood pressure than shorter duration undocumented immigrants. The findings suggest that the "health advantage" generally presumed to exist among immigrants may not affect undocumented immigrants.

Crisis-Affected Populations and Tuberculosis

By definition, humanitarian crises can severely affect human health, directly through violence or indirectly through breakdown of infrastructure or lack of provision for basic human needs, such as safe shelter, food, clean water, and suitable clothing. After the initial phase, these indirect effects are the most important determinants of morbidity and mortality in humanitarian emergencies, and infectious diseases are among the most significant causes of ill health. Tuberculosis (TB) incidence in humanitarian emergencies varies depending on a number of factors, including the country background epidemiology, but will be elevated compared with precrisis levels. TB morbidity and mortality are associated with access to appropriate care and medications, and will also be elevated due to barriers to access to diagnosis and appropriate treatment, including robust TB drug supplies. While reestablishment of TB control is challenging in the early phases, successful treatment programs have been previously established, and the WHO has issued guidance on establishing such successful programs. Such programs should be closely linked to other health programs and established in close collaboration with the country's national treatment program. Individuals who flee the emergency also have a higher TB risk and can face difficulties accessing care en route to or upon arrival in host countries. These barriers, often associated with treatment delays and worse outcomes, can be the result of uncertainties around legal status, other practical challenges, or lack of health care worker awareness. It is important to recognize and mitigate these barriers with an increasing number of tools now available and described.

Healthcare inequality issues among immigrant elders after neoliberal welfare reform: empirical findings from the United States

Even with the increasing importance being placed on research into immigrant elders' healthcare use as countries change their policies to reflect their increasing immigrant and aging populations, little research has examined changes in healthcare use disparities between immigrant and native elders in relation to these policy changes. To fill this gap in the literature, this study examined healthcare disparities in relation to the welfare reform that the US implemented in 1996 and then compared significant indicators of immigrants' healthcare use during the pre- and post-reform periods. The difference-in-difference (DD) analyses and post hoc probing of the DD analyses were used in multivariate logistic regression of the National Health Information Survey data that were pooled for the pre- and post-reform periods. The results revealed that while inequalities in healthcare existed before the reform, they significantly increased after the reform. A further test showed that the changes in the inequalities were significant among relatively long-stay immigrants, but not significant among immigrants who entered the US before the reform and thus were exempted from the reform restrictions. During the pre-reform period, insurance, employment, sex, and race/ethnicity were related to healthcare use; however, the enabling factors (i.e., insurance, income, and education) and social structural factors (i.e., marital status, family structure, length of US residency, race/ethnicity, and geographical region) explained the post-reform immigrants' healthcare use, while controlling for healthcare needs factors. These findings suggest that welfare reform may be the driving force of inequalities in healthcare.

Reversing welfare reform? Immigrant restoration efforts and food stamp receipt among Mexican immigrant families

The safety net that immigrants face today differs significantly from the immediate post-Welfare Reform era in terms of eligibility and economic context. To inform debates on immigrant access to the safety net, this paper examines implications of the 2002 Farm Security and Rural Investment Act, which restored food stamp eligibility to nearly two-thirds of immigrants who lost eligibility under Welfare Reform. Using data from the 1995-2013 Current Population Survey and a difference-in-difference design, I examine how restoration efforts have influenced food stamp participation and food insecurity rates among low-income Mexican immigrant households with children. I then examine trends in food stamp receipt across policy and economic changes since Welfare Reform. Overall, results suggest that immigrant restoration efforts have reversed some but not all of the negative consequences of Welfare Reform and that immigrant households' use of food stamps has increased, particularly in the wake of the Great Recession.

Changes in Public Prenatal Care Coverage Options for Noncitizens Since Welfare Reform: Wide State Variation Remains

Before 1996, most lawfully present noncitizens were eligible for the same prenatal Medicaid benefits as U.S. citizens. However, the 1996 Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA)-welfare reform-restricted benefits for certain lawful noncitizens for the first time. Welfare reform also gave states unprecedented authority to determine Medicaid eligibility. More recent federal policy changes have allowed states to cover some noncitizen pregnant women initially excluded under welfare reform. However, there are few comprehensive studies examining state implementation of these policy options. This study documents state-level trends in prenatal Medicaid and state-funded coverage options for low-income noncitizens just prior to and since welfare reform. While some states have substantially expanded prenatal coverage since PRWORA, wide variation remains. These findings have important implications for understanding the potential effects of the Affordable Care Act and Medicaid expansion on health care utilization and birth outcomes among pregnant noncitizens.

Policy Implications of a Literature Review of Cardiovascular Disease in Uninsured Immigrant Older Adults

The number of older adults emigrating to the United States is expected to quadruple by 2050. The health of immigrant older adults is complicated by the limited options for low-cost health insurance available to this population. Welfare reform has limited new immigrants' access to public assistance programs, such as Medicaid; and low-cost private insurance options rarely exist for individuals older than 65, even with the passage of the Patient Protection and Affordable Care Act (PPACA). Uninsured immigrant older adults have been found to forgo preventive care due to cost and are among the leading users of emergency departments for preventable complications of chronic disease, primarily cardiovascular disease (CVD). A review of the literature found that insurance coverage has a significant impact on CVD risk among immigrant older adults. The current article discusses the implications of welfare reform initiatives and the shortcomings of the PPACA in addressing the health care needs of immigrant older adults.

Nativity and occupational class disparities in uninsurance and routine preventive care use among Asian Americans

Using data from 1,530 Asian respondents of the 2002-2003 National Latino and Asian American Study, we examined how nativity and occupational class are associated with uninsurance, no routine physical check-up in the past year and no dental/eye exam use in the past year using weighted multivariate logistic regression models. Recent immigrants had increased odds of uninsurance and no dental/eye exam use than US-born Asians which became nonsignificant after controlling for occupational class and covariates. Unemployed and service workers had increased odds of uninsurance than white-collar workers even after controlling for income and limited English proficiency (LEP). Approximately 35-40 % of blue-collar and service workers reported neither type of preventive care use. Even after controlling for LEP, income, uninsurance, having a regular doctor or place of care, service workers had significantly increased odds of no physical check-up and no dental/eye exam use and blue-collar workers had marginally significant increased odds of no dental/eye exam use. Significant occupational disparities exist in access and preventive care use with workers in service occupations being particularly underserved.

Emergency department services use among immigrant and non-immigrant groups in the United States

Immigrants have disproportionate lack of access to healthcare and insurance. Emergency departments could serve as a healthcare substitute and increased demand can negatively affect the US emergency services system. Medical Expenditures Panel Survey (2000-2008) data was modeled to compare emergency departments (ED) use between non-citizens, foreign-born (naturalized), and US-born citizens. Group differences were assessed using non-linear decomposition techniques. Non-citizens were less likely to use ED services (8.7 %) compared to naturalized immigrants (10.6 %) and US-born Americans (14.7 %). Differences in ED use persisted after adjusting for the Behavioral Model covariates. Healthcare need and insurance partially explained the differences in ED use between the groups. Between 2000 and 2008 non-citizen immigrants used markedly less ED services compared to US citizens, regardless of their nation of origin. We also found that demographic and healthcare need profiles contributed to the divergence in use patterns between groups. A less restrictive healthcare policy environment can potentially contribute to lower population disease burden and greater efficiencies in the US health care system.

Covering the remaining uninsured children: almost half of uninsured children live in immigrant families

OBJECTIVE

Previous authors have answered "how many children in immigrant families are uninsured"; we do not know the inverse: "how many uninsured children live in immigrant families." This paper will show the total contribution of having an immigrant parent to the uninsured rate for children in the United States.

DATA SOURCE

Secondary data from the 2008-2010 American Community Survey.

STUDY DESIGN

Descriptive analyses and a multinomial probit model illustrate the relationship between immigration history and insurance status.

PRINCIPAL FINDINGS

In 2010, almost half (42%) of uninsured children lived in an immigrant family. State-level estimates range from a low of 4% in Maine to a high of 69% in California. Two thirds (69%) of these uninsured children are citizens; furthermore, 39% are Medicaid eligible, 39% are not eligible for Medicaid, and eligibility is unknown for the 21% that are low-income, noncitizens.

CONCLUSIONS

In 2000, a third of all uninsured children lived in immigrant families. In 2010, 42% of all uninsured children lived in immigrant families. Initiatives to expand coverage or increase Medicaid and CHIP uptake will require decision makers to develop new policy and outreach approaches to enroll these children so they do not fall further behind.

Are Latino immigrants a burden to safety net services in nontraditional immigrant states? Lessons from Oregon

The significant growth of the Latino population in the midst of an economic recession has invigorated anti-Latino, anti-immigrant sentiments in many US states. One common misconception is that Latino immigrants are a burden to safety net services. This may be particularly true in nontraditional immigrant states that have not historically served Latino immigrants. Oregon data suggest that despite a higher prevalence of poverty, use of safety net services among Latino immigrants in Oregon is lower than that among non-Latino Whites. Immigration status, costs, lack of insurance coverage, and discrimination are among the reasons for this group's limited use of services. Nevertheless, policies designed to strengthen community and institutional support for Latino immigrant families should be considered in the context of current health care and immigration reform efforts.

Food Insecurity and SNAP Participation in Mexican Immigrant Families: The Impact of the Outreach Initiative

We study the factors associated with food insecurity and participation in the Supplemental Nutrition Assistance Program (SNAP) in Mexican immigrant families in the US. Estimates from analyses that control for a rich set of economic, demographic, and geographic variables show that children in Mexican immigrant families are more likely to be food insecure than children in native families, but are less likely to participate in SNAP. Further, more vulnerable groups such as the first-generation Mexican immigrant families, families in the US for less than 5 years, and families with non-citizen children - that are at a higher risk of food insecurity are the least likely to participate in SNAP. Our analysis suggests that the US Department of Agriculture outreach initiative and SNAP expansion under the American Recovery and Reinvestment Act increased SNAP participation of the mixed-status Mexican families. We do not find any evidence that the outreach and ARRA expansion increased SNAP receipt among Mexican immigrant families with only non-citizen members who are likely to be undocumented.

Reconstruction of health-seeking behaviors: a comparative study of three Asian Pacific immigrant groups

In this article, I explore how health-seeking behaviors of immigrants are reconstructed and shaped during the adaptation process by comparing the experiences of three Asian Pacific immigrant groups in Hawaii: Filipinos, Koreans, and Marshallese. A total of 91 participants (52 new immigrants, 22 ethnic community key informants, and 17 service providers) completed in-depth interviews. All three groups of immigrants experienced significant changes in their health-seeking behaviors, but in different ways. Koreans experienced a dramatic decrease in seeking both primary and preventive health care after immigration, whereas Filipinos and Marshallese increased their health-seeking behaviors. Coupled with the previous health care experiences in their home country and individual characteristics, the social context of the host country, to a great degree, influenced the formation of health-seeking behaviors after immigration. The study findings suggest that tailored interventions should take into account the source of behavioral change and difficulties that each immigrant group experiences.

Which states enroll their Medicaid-eligible, citizen children with immigrant parents?

OBJECTIVE

To identify which states achieve comparable enrollment rates for Medicaid-eligible, citizen children with immigrant and nonimmigrant parents.

DATA SOURCE

A total of 810,345 Medicaid-eligible, citizen children drawn from the 2008-2010 American Community Survey.

STUDY DESIGN

This study estimates a state fixed-effects probit model of uninsured status for Medicaid-eligible, citizen children. State and immigrant family interaction variables test whether citizen children in immigrant families have a higher probability of remaining uninsured compared to children in nonimmigrant families. Simulations predict the uninsured rates for Medicaid eligible children in immigrant and nonimmigrant families and rank states by the differences between the two groups.

PRINCIPAL FINDINGS

While some states have insignificant and near zero differences in predicted uninsured rates, many states have enrollment disparities reaching 20 percent points between citizen children with immigrant and nonimmigrant parents.

CONCLUSIONS

Many states have large differences in enrollment rates between their Medicaid-eligible, citizen children with immigrant and nonimmigrant parents. Addressing these enrollment disparities could improve the health status of citizen children in immigrant families and earn Children's Health Insurance Program Reauthorization Act bonus payments for many states.

Welfare as Maternity Leave? Exemptions from Welfare Work Requirements and Maternal Employment

In some states, the Temporary Assistance for Needy Families (TANF) program offers the equivalent of paid maternity leave without job protection to low-income, single mothers of infants. Age-of-youngest-child (AYC) exemptions waive work requirements for TANF recipients after the birth of a child, generally for 3-12 months, depending on the state. This study uses data from the Current Population Survey (1998-2008) to examine whether the availability and length of AYC exemptions are predictive of rates of employment, work, and full-time work among low-educated single mothers with infants. The analysis uses the difference-in-differences (DD) technique, a comparison of outcomes under different policy treatments and between treatment and comparison groups. The results suggest that AYC exemptions are not related to employment or work rates but that living in a state with no AYC exemption is strongly and positively associated with rates of full-time work among low-educated mothers with infants.

Effects of length of stay and language proficiency on health care experiences among immigrants in Canada and the United States

This study sought to examine the influence of length of stay and language proficiency on immigrants' access to and utilization of care in Canada and the United States (U.S,). Data came from the 2007-2008 Canadian Community Health Survey and the National Health Interview Survey. Analyses were limited to foreign-born, non-elderly adults in each country (n = 12,870 in Canada and n = 7440 in the U.S.). Health care indicators included having a usual source of care; annual consultation with a health professional, dentist, and eye doctor; flu shot in the past year; and Pap test in the past 3 years. Logistic regression models were employed to estimate the relative odds of access or use of care, adjusting for need, demographic factors, socioeconomic status, and insurance coverage. In general, rates of health care access and utilization were higher in Canada than the U.S. among all immigrant groups. In both countries, adjusted analyses indicated that immigrants with shorter length of stay (less than 10 years) and limited language proficiency generally had lower rates of access/use compared with those with longer length of stay (10 years or more) and proficiency in each country's official language(s), respectively. There was one exception to this pattern in the U.S.: immigrants with limited English had higher odds of having a recent Pap test relative to English-proficient immigrants. The persistence of disparities in health care experiences based on length of stay and language proficiency in Canada suggests that universal health insurance coverage may not be sufficient for ensuring access to and utilization of primary and preventive care for this population.

Welfare reform and older immigrant adults' Medicaid and health insurance coverage: changes caused by chilling effects of welfare reform, protective citizenship, or distinct effects of labor market condition by citizenship?

OBJECTIVES

To examine how federal noncitizen Medicaid eligibility restriction and generous state policy affect Medicaid and health insurance coverage among older adults with different citizenship status.

METHOD

This study uses an older adult sample (65 years or older) from the Current Population Survey (CPS) and state data and employed a triple difference-in-differences approach to incorporate variations in citizenship status, time, and state eligibility.

RESULTS

Findings show that Medicaid coverage significantly declined among older noncitizens but increased among older naturalized citizens after Welfare Reform. Findings also show that the differences in older noncitizens' health insurance coverage changes were significant between generous and nongenerous states.

DISCUSSION

Medicaid eligibility affects older immigrant adults' Medicaid and health insurance coverage. Findings support the "protective citizenship" hypothesis but not the "chilling effect" and "labor market condition" hypotheses. Opposite patterns of change in Medicaid coverage between naturalized citizens and noncitizens raise doubt about the effectiveness of eligibility restrictions in reducing government spending.

Welfare reform and elderly immigrants' health insurance coverage: the roles of federal and state medicaid eligibility rules

Immigrants' access to federally-funded Medicaid became limited after welfare reform imposed restrictive noncitizen eligibility rules. This study used a representative sample from the Current Population Survey (N = 105,873) and state-level data to examine the effects of these policy changes on elderly immigrants. Triple difference-in-differences analyses show that federal restriction of eligibility had a significantly negative association with elderly immigrants' Medicaid coverage, and generous state eligibility had significantly positive relationships with Medicaid and any health insurance coverage. Findings indicate the important role of eligibility on elderly immigrants' health insurance coverage. Results call for social workers' actions to expand elderly immigrants' Medicaid eligibility.

Beyond welfare reform: reframing undocumented immigrants' entitlement to health care in the United States, a critical review

This article addresses the main scholarly frames that supported the deservingness of unauthorized immigrants to health benefits in the United States (U.S.) following the passage of the Personal Responsibility Work Opportunity Reconciliation Act (PRWORA), known as the Welfare Reform bill, in 1996. Based on a critical literature review, conducted between January 1997 and March 2011, this article begins with an analysis of the public health rhetorics that endorsed immigrants' inclusion into the U.S. health safety net. In this vein, the "cost-saving" and "the effortful immigrant" frames underscore immigrants' contributions to society vis-à-vis their low utilization of health services. These are complemented by a "surveillance" account that claims to protect the American public from communicable diseases. A "maternalistic" frame is also discussed as a tool to safeguard families, and particularly immigrant mothers, in their roles as bearers and caretakers of their American-born children. The analyses of the "chilling" and the "injustice" frames are then introduced to underscore major anthropological contributions to the formulation of counter-mainstream discourses on immigrants' selective inclusion into the U.S. health care system. First, the "chilling effect," defined as the voluntary withdrawal from health benefits, is examined in light of unauthorized immigrants' internalized feelings of undeservingness. Second, an "injustice" narrative highlights both the contributions and the limitations of a social justice paradigm, which advocated for the restoration of government benefits to elderly immigrants and refugees after the passage of PRWORA. By analyzing the contradictions among all these diverse frames, this paper finally reflects on the conceptual challenges faced by medical anthropology, and the social sciences at large, in advancing health equity and human rights paradigms.

STRUCTURAL RACISM AND HEALTH INEQUITIES: Old Issues, New Directions

Racial minorities bear a disproportionate burden of morbidity and mortality. These inequities might be explained by racism, given the fact that racism has restricted the lives of racial minorities and immigrants throughout history. Recent studies have documented that individuals who report experiencing racism have greater rates of illnesses. While this body of research has been invaluable in advancing knowledge on health inequities, it still locates the experiences of racism at the individual level. Yet, the health of social groups is likely most strongly affected by structural, rather than individual, phenomena. The structural forms of racism and their relationship to health inequities remain under-studied. This article reviews several ways of conceptualizing structural racism, with a focus on social segregation, immigration policy, and intergenerational effects. Studies of disparities should more seriously consider the multiple dimensions of structural racism as fundamental causes of health disparities.

STRUCTURAL RACISM AND HEALTH INEQUITIES: Old Issues, New Directions

Racial minorities bear a disproportionate burden of morbidity and mortality. These inequities might be explained by racism, given the fact that racism has restricted the lives of racial minorities and immigrants throughout history. Recent studies have documented that individuals who report experiencing racism have greater rates of illnesses. While this body of research has been invaluable in advancing knowledge on health inequities, it still locates the experiences of racism at the individual level. Yet, the health of social groups is likely most strongly affected by structural, rather than individual, phenomena. The structural forms of racism and their relationship to health inequities remain under-studied. This article reviews several ways of conceptualizing structural racism, with a focus on social segregation, immigration policy, and intergenerational effects. Studies of disparities should more seriously consider the multiple dimensions of structural racism as fundamental causes of health disparities.

Contextual effects on health care access among immigrants: lessons from three ethnic communities in Hawaii

Immigrant health care is the product of the dynamic interaction between societal factors and the individual's socio-economic and cultural characteristics. Our knowledge about immigrant health care, however, has been limited to individual characteristics, without paying attention to the social context in which immigrants reside. This paper explores the effects of social contexts on access to health care among recent immigrants. As a natural experiment, it compares health care experiences of three immigrant groups in Hawaii - Filipinos, Koreans, and Marshallese - who are situated in different social contexts including immigrant health policy, ethnic community, and individual networks. Through household surveys conducted between October 2005 and January 2006, information of 378 recent immigrant adults on health care access, health insurance status, socio-demographic characteristics, linguistic and cultural factors, health status, ethnic community social capital, and social networks was obtained. The results of analyses show that Marshallese respondents have better access to health care than the other two groups, in spite of their lowest socioeconomic status. The high insurance rate of the Marshallese, mainly associated with a state health policy that provides health insurance assistance for the Marshallese, is the major contributor of their greater health care access. While Filipino immigrants do not benefit from state insurance assistance, high levels of health care resources and social capital within the Filipino community enable them to have significantly better health care access than Koreans, who have higher income and educational attainment. Interestingly, the advanced family/kinship networks are associated with better levels of immigrant health care access, while the increase of co-ethnic friend networks is related to lower access to health care. This study implies that restoration of immigrants' eligibility for public health insurance assistance, development of health care resources and social capital within ethnic communities, and mobilization of immigrant networks would be effective starting points to improve health care access among immigrants.

Review: immigrants and health care access, quality, and cost

Inadequate access and poor quality care for immigrants could have serious consequences for their health and that of the overall U.S. population. The authors conducted a systematic search for post-1996, population-based studies of immigrants and health care. Of the 1,559 articles identified, 67 met study criteria of which 77% examined access, 27% quality, and 6% cost. Noncitizens and their children were less likely to have health insurance and a regular source of care and had lower use than the U.S. born. The foreign born or non-English speakers were less satisfied and reported lower ratings and more discrimination. Immigrants incurred lower costs than the U.S. born, except emergency department expenditures for immigrant children. Policy solutions are needed to improve health care for immigrants and their children. Research is needed to elucidate immigrants' nonfinancial barriers, receipt of specific processes of care, cost of care, and health care experiences in nontraditional U.S. destinations.

Immigrant children's reliance on public health insurance in the wake of immigration reform

OBJECTIVES

We sought to determine whether the reversal of the public charge rule of the Illegal Immigration Reform and Immigrant Responsibility Act, which may have required families to pay for benefits previously received at no cost, led to immigrant children becoming increasingly reliant on public health insurance programs.

METHODS

We conducted a secondary data analysis focusing on low-income children sampled in the 1997 through 2004 versions of the National Health Interview Survey.

RESULTS

Between 1997 and 2004, public health insurance enrollments and the numbers of uninsured foreign-born children in the United States increased by 3.1% and 2.7%, respectively. Using multinomial logistic regression models to account for the substantial differences in socioeconomic status between foreign-born and US-born children, we found that low-income US-born children were just as likely as foreign-born children to have public health insurance coverage (odds ratio [OR] = 1.16; 95% confidence interval [CI] = 0.89, 1.52) and that, after 2000, foreign-born children were 1.59 times (95% CI = 1.24, 2.05) more likely than were US-born children to be uninsured (vs publicly insured).

CONCLUSIONS

In the wake of the reversal of the public charge rule, immigrant children are increasingly likely to be uninsured as opposed to relying on public health insurance.

Welfare reform and older immigrants' health insurance coverage

OBJECTIVES

I examined changes in older immigrants' health insurance coverage after welfare reform in the United States to determine whether the reform measures achieved their goal of saving money by reducing Medicaid participation without increasing the number of uninsured people.

METHODS

Data were obtained from older adults who participated in the Current Population Survey's Annual Social and Economic Supplement from 1994 to 1996 and 2001 to 2005. I used logistic regression to estimate changes in the sample's Medicaid and health insurance coverage after welfare reform, paying special attention to noncitizens and recent immigrants.

RESULTS

Older immigrants' health insurance status was associated with their citizenship status and length of stay in the United States. Medicaid participation significantly decreased among noncitizens and recent immigrants but increased among naturalized citizens. Private health insurance and employer-sponsored insurance coverage significantly increased among recent immigrants but decreased among established immigrants and naturalized citizens. The probability of being uninsured did not significantly change among any group of immigrants.

CONCLUSIONS

Given increases in postreform Medicaid participation among some immigrant groups, my findings suggest that the long-term cost-saving effectiveness of the current restrictive Medicaid eligibility policy is doubtful.

Parental nativity affects children's health and access to care

OBJECTIVE

To examine the effect of parental nativity on child health and access to health care.

DATA SOURCE

The 2002 National Survey of America's Families.

RESULTS

Among US children, 14% have foreign-born parents; 5% have one foreign- and one native-born parent ("mixed-nativity"). In multivariate logistic regression analyses, children with foreign-born parents were less likely than children with US-born parents to be perceived in "very good" or "excellent health" [OR = 0.68; 95% CI (0.56-0.82)] and to have a usual health care site [OR = 0.52 (0.38-0.69)]; having mixed-nativity parents is associated with better perceived child health. These effects persisted for minority, but not white, children. Regardless of race and ethnicity, non-citizen children have worse access to care.

CONCLUSION

Efforts to improve children of immigrants' health and access to care should focus on families in which both parents are immigrants, particularly those who are ethnic or racial minorities. Efforts to increase use of health services should focus on non-citizen children.

Welfare reform and the decline in the health-insurance coverage of children of non-permanent residents

The 1996 Welfare Reform Act tightened public health-insurance coverage restrictions for non-permanent residents (NPRs) and altered the eligibility of newly permanent residents (PRs). By drawing on data from the SIPP, this paper explores to what extent welfare reform led to a decline in health-insurance coverage for children of NPRs. This paper proposes that the proportion of uninsured children of NPRs with low social economic status (SES) increased by approximately 10 percentage points relative to their PR counterparts. Furthermore, although eligible for Medicaid, citizen children of NPRs of low SES lost approximately 17 percentage points in coverage.

Dissatisfaction with dental care among mothers of Medicaid-enrolled children

OBJECTIVES

This paper is part of a larger study examining the impact of mothers' having a regular source of dental care (RSDC) on utilization of dental care and oral health of their preschool children. We describe levels of satisfaction with care among mothers whose preschool children were enrolled in Medicaid in Washington State. We report mothers' satisfaction related to having a RSDC by type of dental setting/office.

METHODS

Disproportionate stratified sampling by racial/ethnic group selected 11 305 children aged 3-6 in Medicaid in Washington State. Mothers (n = 4373) completed a mixed-mode survey. Satisfaction with dental care was measured using the Dental Satisfaction Questionnaire (DSQ).

RESULTS

Overall mean DSQ was 57.1 +/- 9.9 (range 18-89). A higher score indicates greater satisfaction. There was not evidence of a difference in dissatisfaction by race/ethnicity but Blacks and Hispanics were less satisfied with pain management than Whites. The majority of respondents agreed with the statement that 'Dentists sometimes act rude to their patients.' Satisfaction is higher for mothers who have a regular private dentist they see consistently versus having a regular dentist through a public or non-profit clinic.

CONCLUSIONS

The satisfaction with dental care for this population is low, and considerably lower than found in other studies for primary medical care. Steps need to be taken to increase dental satisfaction and access to private dental clinics, and to increase perceived quality and pain management of dental care in both private clinics and public/non-profits serving low-income populations.

Disparities in regular source of dental care among mothers of medicaid-enrolled preschool children

For mothers of Medicaid children aged 3 to 6 years, we examined whether mothers' characteristics and local supply of dentists and public dental clinics are associated with having a regular source of dental care. Disproportionate stratified sampling by racial/ethnic group selected 11,305 children aged 3 to 6 in Medicaid in Washington State. Mothers (n=4,373) completed a mixed-mode survey that was combined with dental supply measures. Results reveal 38% of mothers had a regular dental place and 27% had a regular dentist. Dental insurance, greater education, income, length of residence, and better mental health were associated with having a regular place or dentist for Black, Hispanic, and White mothers, along with increased supply of private dentists and safety net clinics for White and Hispanic mothers. Mothers lacking a regular source of dental care may increase oral health disparities disfavoring their children.

Immigrants and health care: sources of vulnerability

Immigrants have been identified as a vulnerable population, but there is heterogeneity in the degree to which they are vulnerable to inadequate health care. Here we examine the factors that affect immigrants' vulnerability, including socioeconomic background; immigration status; limited English proficiency; federal, state, and local policies on access to publicly funded health care; residential location; and stigma and marginalization. We find that, overall, immigrants have lower rates of health insurance, use less health care, and receive lower quality of care than U.S.-born populations; however, there are differences among subgroups. We conclude with policy options for addressing immigrants' vulnerabilities.