How Are Immigrants Faring After Welfare Reform?. Health Status and Insurance Coverage

03/04/2002

How healthy are immigrants? LANYCIS has multiple measures of self-reported health status, but the broadest measure is the response to the simple question: "In general, would you say your [or other person's] health is: excellent, very good, good, fair, or poor?" As seen in Table 1.9, immigrants  both adults and children  generally reported poorer health status than the native-born: 37-39 percent of immigrant adults had excellent or very good health, compared with 51-52 percent of native citizen adults. About 52 percent of immigrant children in Los Angeles and 65 percent in New York City were reported by respondents(27) as being in excellent or very good health, compared with 77 percent for children of native citizens in both California and New York State.

Table 1.9.
Health status among Immigrants,
with Comparison to Natives in California and New York State
  Los Angeles Co. New York City
Excellent or Very Good Good, Fair or Poor Excellent or Very Good Good, Fair or Poor

ADULTS (18-64 years)

Adult immigrants

All immigrants combined

36.9% 62.8% 38.6% 61.3%

Naturalized citizens

43.7% 53.9% 44.1% 55.7%

Lawful permanent residents

34.4% 65.0% 30.3% 69.7%

Refugees or asylees

21.0% 78.7% 38.7% 61.2%

Other legal immigrants

x x 81.3% 18.7%

Undocumented aliens

31.3% 68.6% 35.2% 64.8%

Native citizen adults in CA or NY State*

52.1% 47.9% 50.6% 49.4%

ELDERLY (65 years and older)

Elderly immigrants

All immigrants combined

22.1% 77.4% 17.3% 82.2%

Naturalized citizens

24.7% 75.1% 15.0% 84.7%

Lawful permanent residents

19.0% 80.6% 30.1% 68.8%

Refugees or asylees

x x 3.5% 95.7%

Other legal immigrants

x x x x

Undocumented aliens

x x x x

CHILDREN (0 - 17 years)

Children of immigrants by own status

All immigrants combined 51.5% 48.5% 64.8% 34.5%

Naturalized citizens

x x x x

Lawful permanent residents

53.9% 46.1% 66.3% 33.7%

Refugees or asylees

20.8% 79.2% 52.0% 48.0%

Other legal immigrants

x x x x

Undocumented aliens

53.3% 46.7% x x

Children of immigrants by parents' status

All children in immigrant families 58.7% 41.1% 59.3% 40.4%

Noncitizen children in immigrant fams

51.6% 48.4% 64.3% 34.9%

Citizen children in immigrant families

59.8% 39.9% 58.2% 41.7%

Citizen children in:

       

Naturalized families

61.6% 38.3% 70.9% 28.8%

LPR families

64.9% 34.7% 40.4% 59.6%

Refugee families

48.3% 50.5% x x

Other legal immigrant families

x x x x

Undocumented families

52.5% 47.4% 51.9% 48.1%

Noncitizen children in:

       

Naturalized families

x x x x

LPR families

43.4% 56.6% 65.1% 34.9%

Refugee families

x x x x

Other legal immigrant families

x x x x

Undocumented families

48.5% 51.5% x x

Children of native citizens in CA or NY State*

77.0% 23.0% 76.6% 23.4%

* Comparison group data from the 1999 NSAF. All immigrant data from LANYCIS
"X" denotes small sample size.

However, these findings do not necessarily mean that immigrants are in poorer health than native citizens. Some researchers have hypothesized that immigrants respond to this question differently than the native-born because of cultural differences as opposed to objective health differences. Some ethnic groups, particularly Hispanic and Asian groups, may report poorer health status because of a more fatalistic view of life or because they do not want to appear to "brag."(28) According to a recent National Academy of Sciences report, some studies have found immigrant children to be healthier than similar native citizen children; yet, immigrant children tend to become less healthy the longer they live in the United States (Hernandez and Charney 1998). There are no widely accepted measures for comparing the health status of different cultural groups, so the differences noted here should be interpreted with caution.

Among the immigrant groups surveyed, refugees were the most likely to report poorer health status. This is clinically reasonable, since refugees often come from very harsh environments in their countries of origin and are particularly known to have a high prevalence of illnesses such as tuberculosis (Walker and Jaranson 1999). But here, too, inferences should be drawn cautiously; refugees are more likely to be Asian or Eastern European and may have different cultural responses than other nationalities.

Insurance is a critical determinant of whether a person can get access to health care services. The health insurance profiles of immigrants at all income levels are shown in Table 1.10a (Los Angeles) and Table 1.10b (New York City). They reflect insurance status at the time of the survey and are tabulated so that each person has only one type of insurance assigned.(29)

Table 1.10a.
Health insurance coverage among Immigrants in Los Angeles,
with Comparison to Natives in California
  Uninsured Medicaid Job-Based Insurance Other Private Insurance Medicare/ SCHIP/ Other Public

ADULTS (18-64 years)

Adult immigrants

All immigrants combined

41.8% 8.4% 39.9% 6.0% 3.9%

Naturalized citizens

22.2% 7.4% 57.8% 9.6% 3.0%

Lawful permanent residents

42.0% 10.4% 39.5% 5.2% 2.9%

Refugees or asylees

39.8% 15.1% 40.1% 3.3% 1.7%

Other legal immigrants

x x x x x

Undocumented aliens

71.0% 6.8% 13.9% 2.3% 6.0%

Native citizen adults in California*

15.0% 7.5% 69.9% 6.8% 0.8%

ELDERLY (65 years and over)

Elderly immigrants

All immigrants combined

10.2% 39.2% 19.5% 5.3% 25.8%

Naturalized citizens

9.6% 29.4% 22.2% 6.8% 32.0%

Lawful permanent residents

8.0% 53.1% 18.9% 3.0% 17.0%

Refugees or asylees

x x x x x

Other legal immigrants

x x x x x

Undocumented aliens

x x x x x

CHILDREN (0 - 17 years)

Children of immigrants by parents' status

All children in immigrant families

24.2% 35.5% 28.3% 5.6% 6.4%

Citizen children in immigrant families

21.6% 35.3% 30.9% 5.8% 6.5%

Noncitizen children in immigrant fams

39.7% 37.1% 13.0% 4.1% 6.1%

Citizen children in:

Naturalized families

x x x x x

LPR families

22.4% 35.9% 34.0% 6.6% 1.1%

Refugee families

x x x x x

Other alien families

x x x x x

Undocumented families

24.6% 66.0% 4.9% 1.6% 2.9%

Noncitizen children in:

Naturalized families

x x x x x

LPR families

55.2% 14.5% 11.6% 10.5% 8.2%

Refugee families

6.0% 60.6% 32.2% 0.0% 1.3%

Other alien families

x x x x x

Undocumented families

35.9% 55.3% 1.2% 0.0% 7.7%

Children of native citizens in California*

5.6% 16.6% 68.2% 8.6% 1.0%

* Comparison group data from the 1999 NSAF. All immigrant data from LANYCIS
"X" denotes small sample size.

Table 1.10b.
Health Insurance Coverage Among Immigrants in New York City,
with Comparison to Natives in New York State
  Uninsured Medicaid Job-Based Insurance Other Private Insurance Medicare/ SCHIP/ Other Public

ADULTS (18-64 years)

Adult immigrants

All immigrants combined

38.0% 10.4% 44.2% 4.5% 2.9%

Naturalized citizens

20.5% 10.7% 57.2% 8.4% 3.2%

Lawful permanent residents

40.8% 13.6% 42.3% 1.7% 1.6%

Refugees or asylees

40.5% 17.6% 40.2% 0.8% 0.9%

Other legal immigrants

21.3% 0.3% 58.2% 7.7% 12.6%

Undocumented aliens

79.4% 1.1% 13.4% 2.5% 3.6%

Native citizen adults in New York State*

11.4% 7.8% 75.8% 4.1% 0.9%

ELDERLY (65 years and over)

Elderly immigrants

All immigrants combined

5.5% 45.8% 21.9% 5.2% 21.6%

Naturalized citizens

5.5% 37.4% 24.8% 4.5% 27.8%

Lawful permanent residents

6.7% 47.8% 20.5% 9.7% 15.4%

Refugees or asylees

2.5% 84.3% 10.6% 0.0% 2.7%

Other legal immigrants

x x x x x

Undocumented aliens

x x x x x

CHILDREN (0 - 17 years)

Children of immigrants by parents' status

All children in immigrant families

11.8% 28.3% 40.9% 4.9% 14.1%

Citizen children in immigrant families

8.3% 29.3% 44.0% 5.2% 13.2%

Noncitizen children in immigrant fams

27.8% 24.0% 26.4% 3.3% 18.5%

Citizen children in:

Naturalized families

x x x x x

LPR families

14.5% 35.7% 38.3% 6.5% 5.0%

Refugee families

x x x x x

Other alien families

x x x x x

Undocumented families

x x x x x

Noncitizen children in:

Naturalized families

x x x x x

LPR families

31.7% 31.1% 20.7% 3.9% 12.7%

Refugee families

13.0% 25.3% 55.7% 0.7% 5.4%

Other alien families

x x x x x

Undocumented families

x x x x x

Children of native citizens in New York State*

6.3% 17.2% 68.1% 3.2% 5.3%

* Comparison group data from the 1999 NSAF. All immigrant data from LANYCIS
"X" denotes small sample size.

In both cities, the insurance profiles for immigrant adults were similar: about two-fifths had job-based insurance, two-fifths were uninsured, roughly one-tenth were on Medicaid, and the balance had other private or public insurance. Among the immigrant adults, undocumented aliens were the most likely to be uninsured (71 percent in Los Angeles; 80 percent in New York City) and naturalized citizens were the least likely (22 percent in Los Angeles; 21 percent in New York City). A small percentage of undocumented adults reported having Medicaid. (Although they are ineligible for full Medicaid coverage, they are eligible for emergency benefits.) Consistent with the exemptions under the law, refugees were more likely than LPRs to have Medicaid, but both large shares of both groups were uninsured.

The shares of native citizen adults without health insurance in New York State and California were about one third as high as the uninsured shares among immigrants in the two cities. The native-born were slightly less likely to receive Medicaid but much more likely to have job-based insurance than immigrant adults. Much of the difference in insurance status between immigrants and the native-born may be related to employment, income and other socioeconomic differences of the two groups. On the one hand, immigrants are more frequently employed in lower wage jobs that do not carry benefits such as health insurance. On the other hand, since immigrants are poorer on average than native citizens, they are more likely to receive Medicaid. After controlling for factors like income, education, and health status, however, an earlier study found that noncitizen immigrant adults were significantly less likely to have Medicaid than native citizen adults (Ku and Matani 2001).

A moderate fraction of elderly immigrants were uninsured: 10 percent in Los Angeles and 6 percent in New York City. Although these levels are quite low compared with non-elderly adults, they are substantially higher than the national share of all elders who are uninsured (1 percent, National Center for Health Statistics 1999). Uninsured shares were about the same for elderly noncitizens as for naturalized citizens in both cities. For elderly immigrants in the two cities, the most common source of insurance was Medicaid, which covered 39 percent of the elderly in Los Angeles and 46 percent in New York. About one fifth of the elderly carried job-based insurance (including insurance for retired workers or their dependents) and another one-fifth to one-quarter used Medicare.

Because these tables use an insurance hierarchy, however, they mask total participation in Medicare. When the hierarchy is removed, 75 percent of all elderly immigrants report getting Medicare, regardless of whether they also got another form of coverage (68 percent in Los Angeles and 79 percent in New York, not shown in the tables). By comparison, 96 percent of all seniors in the United States get Medicare (National Center for Health Statistics 1999).

While Medicare is the bulwark of insurance for almost all elderly Americans, many elderly immigrants do not receive it because they (or their spouses) did not work long enough in covered employment in the United States to be eligible. Those with too few years of Medicare-covered employment may purchase coverage, for up to $300 per month for hospital insurance and $50 per month for other medical insurance, but such expenditures may be beyond the reach of many elderly immigrants.(30) In a similar fashion, many elderly do not get Social Security payments because they did not work in the United States long enough. Due to these Medicare eligibility requirements, immigrant elders rely relatively more heavily on Medicaid coverage than do native-born citizens.

These findings are similar to those of Friedland and Pankaj (1997), who have reported that, nationally, 74 percent of elderly immigrants had Medicare in 1993, compared to 97 percent of elderly citizens. They also noted that Medicaid was relatively more important for immigrants, covering 64 percent of them (48 percent on both programs and 16 percent on Medicaid alone), while 12 percent of elderly citizens used Medicaid (11 percent on both programs and 1 percent on Medicaid alone). They found that elderly immigrants who had arrived between the ages of 41 and 64 were twice as likely to be on Medicare as those who entered after age 65. While the almost-universal nature of Medicare coverage has come close to eliminating uninsurance as a problem for elderly citizens, there are noticeable gaps in the Medicare coverage for noncitizens. These authors also noted that the PRWORA-related changes in the eligibility of elderly legal immigrants for Supplemental Security Income will lead to a loss of Medicaid coverage, which could exacerbate the uninsurance among elderly immigrants.

For children, the survey illustrates that there were sizeable differences in the insurance patterns in Los Angeles and New York. Almost one-quarter of the children of immigrants were uninsured in Los Angeles, with 40 percent uninsurance among noncitizen children but only 22 percent among citizen children with immigrant parents.

Shares of children without health insurance were consistently lower in New York City: 12 percent overall, with 28 percent for noncitizen children and 8 percent for citizen children in immigrant families. A key reason for the difference is that more immigrant children were on SCHIP in New York City (14 percent) than in Los Angeles (6 percent). Both New York State and California let legal immigrant children participate in their SCHIP programs, but New York's program has been operating for much longer and has about twice the caseload (Ellis and Smith 2000). Immigrant children were also more likely to have insurance provided through their parents' employers in New York than were those in Los Angeles.

The data show that noncitizen children with LPR parents were more likely to be uninsured (55 percent in Los Angeles and 32 percent in New York City) than citizen children in LPR families (22 percent in Los Angeles and 15 percent in New York City). These rates were much higher than the uninsurance rates of native citizen children in the two states (6 percent in each). Ku and Matani (2001) found that, after controlling for factors like income, education, race/ethnicity, and health status, both noncitizen and citizen children in immigrant families were more likely to be uninsured and less likely to have Medicaid or job-based insurance than children in citizen families.

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