Health care use among undocumented latino immigrants

Health Affairs

Volumn 19, Issue 4, 2000, Pages 51-64

  Berk, Marc L ^a   Schur, Claudia L ^a   Chavez, Leo R ^b   Frankel, Martin ^c  

^a Project HOPE Center for Health Affairs   (United States)

^b UNIVERSITY OF CALIFORNIA   (United States)

^c CITY UNIVERSITY OF NEW YORK   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

ADOLESCENT; ADULT; AGED; AMBULATORY CARE; ARTICLE; CHILD; EPIDEMIOLOGY; FEMALE; HISPANIC; HOSPITALIZATION; HUMAN; INFANT; MALE; MIDDLE AGED; MIGRATION; NEWBORN; PREGNANCY; PRESCHOOL CHILD; STATISTICS; UNITED STATES; URBAN POPULATION; UTILIZATION REVIEW;

ADOLESCENT; ADULT; AGED; AMBULATORY CARE; CALIFORNIA; CHILD; CHILD, PRESCHOOL; EMIGRATION AND IMMIGRATION; FEMALE; HEALTH CARE SURVEYS; HISPANIC AMERICANS; HOSPITALIZATION; HUMANS; INFANT; INFANT, NEWBORN; MALE; MIDDLE AGED; PREGNANCY; TEXAS; URBAN POPULATION; UTILIZATION REVIEW;

EID: 2942575600     PISSN: 02782715     EISSN: None     Source Type: Journal    
DOI: 10.1377/hlthaff.19.4.51     Document Type: Article

References (44)

1. The term undocumented refers here to persons who entered the country without inspection as well as persons who violated the terms of their visas.
2. INS Fact Sheet, www.ins.usdoj.gov/hqopp/factsfin.htm, updated 31 January 1997. While PRWORA contains this stipulation, it is not clear whether the stipulation is legal or enforceable.
3. "Governor Goes Public with Fight to Reduce Services States Provide," Fresno Bee, 9 August 1993.
4. Ballot Pamphlets are regularly prepared by the office of the secretary of state to inform voters about the propositions at each election. They generally include an analysis of the proposition with arguments for and against it.
5. Although the courts suspended implementation of the health, education, and human services provisions of Proposition 187, the debate continues in a similar fashion. See K. Johnson, "Public Benefits and Immigration: The Intersection of Immigration Status, Ethnicity, Gender, and Class," UCLA Low Review 42 (1995): 1509-1575.
6. See, for example, R. Clark et al., Fiscal Impacts of Undocumented Aliens: Selected Estimates for Seven States (Washington: Urban Institute, 1994); U.S. General Accounting Office, Illegal Aliens: National Net Cost Estimates Vary Widely, Pub. no. GAO/HEHS-95-133 (Washington: GAO, 1995); GAO, Illegal Aliens: Assessing Estimates of Financial Burden on California, Pub. no. GAO/HEHS-95-22 (Washington: GAO, 1994); S. Norton, G. Kenney, and M. Ellwood, "Medicaid Coverage of Maternity Care for Aliens in California," Family Planning Perspectives 28, no. 3 (1996): 108-112; and L. Ku and B. Kessler, The Number and Cost of Immigrants on Medicaid: National and State Estimates (Washington: Urban Institute, 1997).
7. See, for example, R. Clark et al., Fiscal Impacts of Undocumented Aliens: Selected Estimates for Seven States (Washington: Urban Institute, 1994); U.S. General Accounting Office, Illegal Aliens: National Net Cost Estimates Vary Widely, Pub. no. GAO/HEHS-95-133 (Washington: GAO, 1995); GAO, Illegal Aliens: Assessing Estimates of Financial Burden on California, Pub. no. GAO/HEHS-95-22 (Washington: GAO, 1994); S. Norton, G. Kenney, and M. Ellwood, "Medicaid Coverage of Maternity Care for Aliens in California," Family Planning Perspectives 28, no. 3 (1996): 108-112; and L. Ku and B. Kessler, The Number and Cost of Immigrants on Medicaid: National and State Estimates (Washington: Urban Institute, 1997).
8. See, for example, R. Clark et al., Fiscal Impacts of Undocumented Aliens: Selected Estimates for Seven States (Washington: Urban Institute, 1994); U.S. General Accounting Office, Illegal Aliens: National Net Cost Estimates Vary Widely, Pub. no. GAO/HEHS-95-133 (Washington: GAO, 1995); GAO, Illegal Aliens: Assessing Estimates of Financial Burden on California, Pub. no. GAO/HEHS-95-22 (Washington: GAO, 1994); S. Norton, G. Kenney, and M. Ellwood, "Medicaid Coverage of Maternity Care for Aliens in California," Family Planning Perspectives 28, no. 3 (1996): 108-112; and L. Ku and B. Kessler, The Number and Cost of Immigrants on Medicaid: National and State Estimates (Washington: Urban Institute, 1997).
9. See, for example, R. Clark et al., Fiscal Impacts of Undocumented Aliens: Selected Estimates for Seven States (Washington: Urban Institute, 1994); U.S. General Accounting Office, Illegal Aliens: National Net Cost Estimates Vary Widely, Pub. no. GAO/HEHS-95-133 (Washington: GAO, 1995); GAO, Illegal Aliens: Assessing Estimates of Financial Burden on California, Pub. no. GAO/HEHS-95-22 (Washington: GAO, 1994); S. Norton, G. Kenney, and M. Ellwood, "Medicaid Coverage of Maternity Care for Aliens in California," Family Planning Perspectives 28, no. 3 (1996): 108-112; and L. Ku and B. Kessler, The Number and Cost of Immigrants on Medicaid: National and State Estimates (Washington: Urban Institute, 1997).
10. See, for example, R. Clark et al., Fiscal Impacts of Undocumented Aliens: Selected Estimates for Seven States (Washington: Urban Institute, 1994); U.S. General Accounting Office, Illegal Aliens: National Net Cost Estimates Vary Widely, Pub. no. GAO/HEHS-95-133 (Washington: GAO, 1995); GAO, Illegal Aliens: Assessing Estimates of Financial Burden on California, Pub. no. GAO/HEHS-95-22 (Washington: GAO, 1994); S. Norton, G. Kenney, and M. Ellwood, "Medicaid Coverage of Maternity Care for Aliens in California," Family Planning Perspectives 28, no. 3 (1996): 108-112; and L. Ku and B. Kessler, The Number and Cost of Immigrants on Medicaid: National and State Estimates (Washington: Urban Institute, 1997).
11. F. Hubbell et al., "Access to Medical Care for Documented and Undocumented Latinos in a Southern California County," Western Journal of Medicine 154, no. 4 (1991): 414-417; and L. Chavez et al., "Undocumented Latina Immigrants in Orange County, California: A Comparative Analysis," International Migration Review 31, no. 1(1997): 88-107.
12. F. Hubbell et al., "Access to Medical Care for Documented and Undocumented Latinos in a Southern California County," Western Journal of Medicine 154, no. 4 (1991): 414-417; and L. Chavez et al., "Undocumented Latina Immigrants in Orange County, California: A Comparative Analysis," International Migration Review 31, no. 1(1997): 88-107.
13. The decision to limit the survey to Latinos and to four geographic sites was made for both policy and operational reasons. Identifying a sample that was representative of all undocumented immigrants in the United States would have required a level of resources not available to the health services research community. Moreover, a nationally representative sample would not allow for inferences about specific communities; since there is likely to be substantial variation across geographic areas, limiting analyses to overall national estimates might be less useful for policy purposes.
14. Probability sampling is defined by each member of the group of interest having a known probability of being selected for an interview.
15. In convenience samples, the study population is made up of people who come forward and volunteer to participate. In snowball methodologies, one starts with a limited sample and augments it by asking respondents to identify others who meet the study criteria. See, for example, L. Chavez, E. Flores, and M. Lopez-Garza, "Undocumented Latin American Immigrants and U.S. Health Services: An Approach to a Political Economy of Utilization," Medical Anthropology Quarterly 6, no. 1 (1992): 6-26; L. Chavez, W. Cornelius, and O. Jones, "Utilization of Health Services by Mexican Immigrant Women in San Diego," Women and Health 11, no. 2 (1986): 3-20; L. Chavez, W. Cornelius, and O. Jones, "Mexican Immigrants and the Utilization of U.S. Health Services: The Case of San Diego," Social Science and Medicine 21, no. 1 (1985): 93-102; W. Cornelius, "Interviewing Undocumented Immigrants: Methodological Reflections Based on Fieldwork in Mexico and the U.S.," International Migration Review 16, no. 2 (1982): 378-411; and K. Siddharthan and M. Ahern, "Inpatient Utilization by Undocumented Immigrants without Insurance," Journal of Health Care for the Poor and Underserved 7, no. 4 (1996): 355-362.
16. In convenience samples, the study population is made up of people who come forward and volunteer to participate. In snowball methodologies, one starts with a limited sample and augments it by asking respondents to identify others who meet the study criteria. See, for example, L. Chavez, E. Flores, and M. Lopez-Garza, "Undocumented Latin American Immigrants and U.S. Health Services: An Approach to a Political Economy of Utilization," Medical Anthropology Quarterly 6, no. 1 (1992): 6-26; L. Chavez, W. Cornelius, and O. Jones, "Utilization of Health Services by Mexican Immigrant Women in San Diego," Women and Health 11, no. 2 (1986): 3-20; L. Chavez, W. Cornelius, and O. Jones, "Mexican Immigrants and the Utilization of U.S. Health Services: The Case of San Diego," Social Science and Medicine 21, no. 1 (1985): 93-102; W. Cornelius, "Interviewing Undocumented Immigrants: Methodological Reflections Based on Fieldwork in Mexico and the U.S.," International Migration Review 16, no. 2 (1982): 378-411; and K. Siddharthan and M. Ahern, "Inpatient Utilization by Undocumented Immigrants without Insurance," Journal of Health Care for the Poor and Underserved 7, no. 4 (1996): 355-362.
17. In convenience samples, the study population is made up of people who come forward and volunteer to participate. In snowball methodologies, one starts with a limited sample and augments it by asking respondents to identify others who meet the study criteria. See, for example, L. Chavez, E. Flores, and M. Lopez-Garza, "Undocumented Latin American Immigrants and U.S. Health Services: An Approach to a Political Economy of Utilization," Medical Anthropology Quarterly 6, no. 1 (1992): 6-26; L. Chavez, W. Cornelius, and O. Jones, "Utilization of Health Services by Mexican Immigrant Women in San Diego," Women and Health 11, no. 2 (1986): 3-20; L. Chavez, W. Cornelius, and O. Jones, "Mexican Immigrants and the Utilization of U.S. Health Services: The Case of San Diego," Social Science and Medicine 21, no. 1 (1985): 93-102; W. Cornelius, "Interviewing Undocumented Immigrants: Methodological Reflections Based on Fieldwork in Mexico and the U.S.," International Migration Review 16, no. 2 (1982): 378-411; and K. Siddharthan and M. Ahern, "Inpatient Utilization by Undocumented Immigrants without Insurance," Journal of Health Care for the Poor and Underserved 7, no. 4 (1996): 355-362.
18. In convenience samples, the study population is made up of people who come forward and volunteer to participate. In snowball methodologies, one starts with a limited sample and augments it by asking respondents to identify others who meet the study criteria. See, for example, L. Chavez, E. Flores, and M. Lopez-Garza, "Undocumented Latin American Immigrants and U.S. Health Services: An Approach to a Political Economy of Utilization," Medical Anthropology Quarterly 6, no. 1 (1992): 6-26; L. Chavez, W. Cornelius, and O. Jones, "Utilization of Health Services by Mexican Immigrant Women in San Diego," Women and Health 11, no. 2 (1986): 3-20; L. Chavez, W. Cornelius, and O. Jones, "Mexican Immigrants and the Utilization of U.S. Health Services: The Case of San Diego," Social Science and Medicine 21, no. 1 (1985): 93-102; W. Cornelius, "Interviewing Undocumented Immigrants: Methodological Reflections Based on Fieldwork in Mexico and the U.S.," International Migration Review 16, no. 2 (1982): 378-411; and K. Siddharthan and M. Ahern, "Inpatient Utilization by Undocumented Immigrants without Insurance," Journal of Health Care for the Poor and Underserved 7, no. 4 (1996): 355-362.
19. In convenience samples, the study population is made up of people who come forward and volunteer to participate. In snowball methodologies, one starts with a limited sample and augments it by asking respondents to identify others who meet the study criteria. See, for example, L. Chavez, E. Flores, and M. Lopez-Garza, "Undocumented Latin American Immigrants and U.S. Health Services: An Approach to a Political Economy of Utilization," Medical Anthropology Quarterly 6, no. 1 (1992): 6-26; L. Chavez, W. Cornelius, and O. Jones, "Utilization of Health Services by Mexican Immigrant Women in San Diego," Women and Health 11, no. 2 (1986): 3-20; L. Chavez, W. Cornelius, and O. Jones, "Mexican Immigrants and the Utilization of U.S. Health Services: The Case of San Diego," Social Science and Medicine 21, no. 1 (1985): 93-102; W. Cornelius, "Interviewing Undocumented Immigrants: Methodological Reflections Based on Fieldwork in Mexico and the U.S.," International Migration Review 16, no. 2 (1982): 378-411; and K. Siddharthan and M. Ahern, "Inpatient Utilization by Undocumented Immigrants without Insurance," Journal of Health Care for the Poor and Underserved 7, no. 4 (1996): 355-362.
20. See, for example, K. Siddharthan and S. Alalasundaram, "Undocumented Aliens and Uncompensated Care: Whose Responsibility?" American Journal of Public Health 83, no. 3 (1993): 410-412; T. Chan et al., "Survey of Illegal Immigrants Seen in an Emergency Department," Western Journal of Medicine 164, no. 3 (1996): 212-216; S. Asch et al., "Potential Impact of Restricting STD/HIV Care for Immigrants in Los Angeles County," International Journal of STDs and AIDS 7, no. 7 (1996): 532-535; and Norton et al., "Medicaid Coverage of Maternity Care."
21. See, for example, K. Siddharthan and S. Alalasundaram, "Undocumented Aliens and Uncompensated Care: Whose Responsibility?" American Journal of Public Health 83, no. 3 (1993): 410-412; T. Chan et al., "Survey of Illegal Immigrants Seen in an Emergency Department," Western Journal of Medicine 164, no. 3 (1996): 212-216; S. Asch et al., "Potential Impact of Restricting STD/HIV Care for Immigrants in Los Angeles County," International Journal of STDs and AIDS 7, no. 7 (1996): 532-535; and Norton et al., "Medicaid Coverage of Maternity Care."
22. See, for example, K. Siddharthan and S. Alalasundaram, "Undocumented Aliens and Uncompensated Care: Whose Responsibility?" American Journal of Public Health 83, no. 3 (1993): 410-412; T. Chan et al., "Survey of Illegal Immigrants Seen in an Emergency Department," Western Journal of Medicine 164, no. 3 (1996): 212-216; S. Asch et al., "Potential Impact of Restricting STD/HIV Care for Immigrants in Los Angeles County," International Journal of STDs and AIDS 7, no. 7 (1996): 532-535; and Norton et al., "Medicaid Coverage of Maternity Care."
23. See, for example, K. Siddharthan and S. Alalasundaram, "Undocumented Aliens and Uncompensated Care: Whose Responsibility?" American Journal of Public Health 83, no. 3 (1993): 410-412; T. Chan et al., "Survey of Illegal Immigrants Seen in an Emergency Department," Western Journal of Medicine 164, no. 3 (1996): 212-216; S. Asch et al., "Potential Impact of Restricting STD/HIV Care for Immigrants in Los Angeles County," International Journal of STDs and AIDS 7, no. 7 (1996): 532-535; and Norton et al., "Medicaid Coverage of Maternity Care."
24. J. Passel, unpublished estimates (Washington: Urban Institute, 1995). Immigration and Naturalization Service (INS) estimates indicate that 54 percent of undocumented persons live in California and Texas; another 29 percent live in New York, Florida, Illinois, New Jersey, and Arizona (U.S. Department of Justice, 1997).
25. INS, "INS Releases Updated Estimates of U.S. Illegal Population" (Press release, 7 February 1997).
26. For a household to be counted as linguistically isolated, Spanish must be spoken in the household, and there can be no one living in the household age fourteen or older who speaks only English or who speaks English very well.
27. "Listing" involves creating a complete enumeration of all possible dwelling units in a geographic area. Although lists of addresses are commercially available, the pretest revealed that these lists were not adequate for finding all places where the target population might live, including informal, illegal, or other hidden housing units. Thus, in-person canvassing was conducted to verify all addresses. Details about the sample design are described in C. Good, R. Jacinto, and M. Berk, "Surveying Rare Populations with Probability Sampling: The Case of Interviewing Undocumented Immigrants" (Paper presented at the American Association for Public Opinion Research Annual Conference, St. Louis, Missouri, 1998).
28. It is likely that those whom we excluded were even less likely to use health care services than those who were here for longer periods or permanently. Family units were defined to include spouses and children under age eighteen residing in the household.
29. The response rate varied across sites (69 percent in Fresno, 87 percent in Los Angeles, 83 percent in El Paso, and 55 percent in Houston). This rate is calculated at the household level as the number of completed interviews divided by the sum of eligible households plus a proportion of nonscreened households for whom eligibility status is unknown. The proportion of nonscreened households included in the denominator is based on the proportion of eligible households found among all screened households. We assume that the proportion of screened households that are eligible is the same as the proportion of nonscreened households that would be eligible.
30. Chi-squares are used to compare distributions of characteristics across sites; the chi-square is used to test the null hypothesis that the distribution of a given characteristic is the same across sites. T-tests are used for comparisons across sites when examining participation in government programs and between the undocumented population and national estimates from the NHIS. Standard errors were computed using SUDAAN, which uses the Taylor series linearization method to account for the complex survey design.
31. Only health care obtained within the United States is included in this discussion. Because El Paso is located near the Mexico/U.S. border and adjacent to a large metropolitan area (Ciudad Juarez), persons in El Paso may be more likely than are those in the other sites to obtain health care in Mexico. Patterns of health care use do not appear to be substantially different, however.
32. The Omnibus Budget Reconciliation Act (OBRA) of 1986 mandated coverage of emergency medical services (including childbirth services) under Medicaid for aliens without satisfactory immigration status if they met certain eligibility requirements. In that same year the Los Angeles County health director proclaimed that undocumented aliens were required to apply for Medicaid benefits so that the county could recover some expenses until eligibility had been determined. Chavez et al., "Undocumented Latin American Immigrants." In 1988 California began to provide nonemergency pregnancy-related care, including prenatal care, labor, delivery, and postpartum care, as a state-only funded benefit to undocumented aliens who met certain eligibility requirements. Thus, these services were available at the time of the survey. With the passage of PRWORA and amended sections of the legislation, undocumented immigrants are ineligible for federally funded health care with the exception of emergency services (including labor and delivery), public health immunizations, and testing for and treatment of communicable diseases. The law requires the elimination of this state-only benefit unless the state legislature passes specific legislation.
33. In 1995 undocumented alien mothers were covered by Medicaid for 78,386 births in California and 24,549 births in Texas - 14 and 8 percent, respectively, of all Medicaid births in those state for that year. GAO, Undocumented Aliens: Medicaid-Funded Births in California and Texas, Pub. no. GAO/HEHS-97-124R (Washington: GAO, 1997).
34. PRWORA consolidated three federal/state matching-grant programs - AFDC, Emergency Assistance (EA), and the Job Opportunities and Basic Skills (JOBS) training program - into one block-grant program. The new program, Temporary Assistance for Needy Families (TANF), gives states considerable spending flexibility but also imposes new work requirements and time limits for welfare recipients. As was the case with AFDC, undocumented immigrants are not eligible for TANF. All interviews were conducted prior to TANF's implementation on 1 July 1997. In addition to these federal/state programs, California and Texas each provide some local public assistance to indigent persons.
35. Inability to obtain care refers to a "yes" in response to either of the following questions: "In the last 12 months, was there a time that you wanted medical attention or an operation but you could not get it at that time?" or "In the last 12 months, was there a time when you wanted a prescription filled, but you could not get it at that time?"
36. J. Arnold et al., Undocumented Persons in a Health Care Reform Environment (Falls Church, Va.: Lewin Group, 1994).
37. Chavez et al., "Undocumented Latina Immigrants in Orange County."
38. For a discussion of state strategies in the face of the new legislation, see L. Flowers-Bovvie, Funding Prenatal Care for Unauthorized Immigrants: Challenges for the States (Washington: National Conference of State Legislatures, 1997).
39. Ibid.; G. Wilensky and M.L. Berk, "Health Care, the Poor, and the Role of Medicaid," Health Affairs (Fall 1982): 93-100; M.L. Berk and C.L. Schur, "Access to Care: How Much Difference Does Medicaid Make?" Health Affairs (May/June 1998): 169-180; A.T. Fragomen Jr., "The Illegal Immigration Reform and Immigrant Responsibility Act of 1996: An Overview," International Migration Review 31, no. 2 (1997): 438-460; Johnson, "Public Benefits and Immigration," 1509; and GAO, Undocumented Aliens.
40. Ibid.; G. Wilensky and M.L. Berk, "Health Care, the Poor, and the Role of Medicaid," Health Affairs (Fall 1982): 93-100; M.L. Berk and C.L. Schur, "Access to Care: How Much Difference Does Medicaid Make?" Health Affairs (May/June 1998): 169-180; A.T. Fragomen Jr., "The Illegal Immigration Reform and Immigrant Responsibility Act of 1996: An Overview," International Migration Review 31, no. 2 (1997): 438-460; Johnson, "Public Benefits and Immigration," 1509; and GAO, Undocumented Aliens.
41. Ibid.; G. Wilensky and M.L. Berk, "Health Care, the Poor, and the Role of Medicaid," Health Affairs (Fall 1982): 93-100; M.L. Berk and C.L. Schur, "Access to Care: How Much Difference Does Medicaid Make?" Health Affairs (May/June 1998): 169-180; A.T. Fragomen Jr., "The Illegal Immigration Reform and Immigrant Responsibility Act of 1996: An Overview," International Migration Review 31, no. 2 (1997): 438-460; Johnson, "Public Benefits and Immigration," 1509; and GAO, Undocumented Aliens.
42. Ibid.; G. Wilensky and M.L. Berk, "Health Care, the Poor, and the Role of Medicaid," Health Affairs (Fall 1982): 93-100; M.L. Berk and C.L. Schur, "Access to Care: How Much Difference Does Medicaid Make?" Health Affairs (May/June 1998): 169-180; A.T. Fragomen Jr., "The Illegal Immigration Reform and Immigrant Responsibility Act of 1996: An Overview," International Migration Review 31, no. 2 (1997): 438-460; Johnson, "Public Benefits and Immigration," 1509; and GAO, Undocumented Aliens.
43. Ibid.; G. Wilensky and M.L. Berk, "Health Care, the Poor, and the Role of Medicaid," Health Affairs (Fall 1982): 93-100; M.L. Berk and C.L. Schur, "Access to Care: How Much Difference Does Medicaid Make?" Health Affairs (May/June 1998): 169-180; A.T. Fragomen Jr., "The Illegal Immigration Reform and Immigrant Responsibility Act of 1996: An Overview," International Migration Review 31, no. 2 (1997): 438-460; Johnson, "Public Benefits and Immigration," 1509; and GAO, Undocumented Aliens.
44. Ibid.; G. Wilensky and M.L. Berk, "Health Care, the Poor, and the Role of Medicaid," Health Affairs (Fall 1982): 93-100; M.L. Berk and C.L. Schur, "Access to Care: How Much Difference Does Medicaid Make?" Health Affairs (May/June 1998): 169-180; A.T. Fragomen Jr., "The Illegal Immigration Reform and Immigrant Responsibility Act of 1996: An Overview," International Migration Review 31, no. 2 (1997): 438-460; Johnson, "Public Benefits and Immigration," 1509; and GAO, Undocumented Aliens.