J Immigrant Minority Health (2012) 14:345–349 DOI 10.1007/s10903-010-9411-z
BRIEF COMMUNICATION
Health Insurance Moderates the Association Between Immigrant Length of Stay and Health Status Sunmin Lee • Allison O’Neill • Julie Park Lynn Scully • Edmond Shenassa
•
Published online: 9 November 2010 Ó Springer Science+Business Media, LLC 2010
Abstract Previous studies reported that immigrants’ health worsens with acculturation to US lifestyle; however, role of health insurance has not been investigated. We used crosssectional National Immigrant Survey (n = 6,381) to examine the potential moderating effect of health insurance on the association between time in the US and self reported changes in health (comparing health status before and after immigration) and current health status. Separate logistic regression models were fit to assess these associations among insured and uninsured immigrants, adjusting for covariates. Among uninsured immigrants there was a stronger negative association between length of stay and health, compared to immigrants with health insurance. Insured immigrants were almost two times more likely than uninsured immigrants to have received preventive screenings, such as a Pap smear or prostate exam. This suggests that health insurance may somewhat attenuate this association, and is an important resource for US immigrants. Keywords Health insurance Immigrant acculturation Health status Screening
S. Lee (&) A. O’Neill L. Scully E. Shenassa Department of Epidemiology and Biostatistics, University of Maryland School of Public Health, 2234C SPH Bldg, College Park, MD 20742, USA e-mail:
[email protected] J. Park Department of Sociology, University of Maryland, College Park, MD, USA E. Shenassa Department of Family Science, University of Maryland, College Park, MD, USA
Introduction Immigrants now account for 12.6% of the United States (US) population [1] so their adaptation process has been a keen interest of policymakers and researchers alike. Immigrants arrive in the US with generally better health than their native-born counterparts [2, 3]. This healthy immigrant effect however, is often followed by unhealthy assimilation [4, 5]. Immigrants’ apparent health advantage disappears as they become more acculturated to living in the US and change their health attitudes, beliefs, and behaviors [6–8]. As immigrants become a growing part of the US population, it is imperative that we begin to understand how this ‘‘unhealthy assimilation’’ process may be tempered. A potential moderator for deteriorating health status may be health insurance coverage. Health insurance facilitates use of health services including preventive services, improves general health and physical functioning as well as outcomes in both chronic and acute conditions [9], and is associated with a 40% decrease in the likelihood of premature death [10]. Also, screening behaviors such as mammograms and pap smears in immigrant populations have been shown to be associated with health insurance status [11], as well as English language proficiency [12, 13], and length of stay in the US [13–15]. Unfortunately, immigrants have some of the highest uninsured rates in the US [16] with 33.5% uninsured among immigrants (vs. 12.9% of native-born residents) [17]. Furthermore, even after controlling for demographic and socioeconomic characteristics, the most recent arrivals are the most likely to be uninsured among all immigrants [18]. Previous research has examined the relationship between length of US residence and health status of immigrants. However, due to data limitations, researchers
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have not previously been able to examine changes in health status of immigrants comparing health status before and after immigration to the US. Secondly, to the best of our knowledge, there are no published studies examining the relationship between immigrants’ length of US residence and self reported health status with health insurance coverage as a potential moderator. In the current study, using the New Immigrant Survey (NIS), we examine the potential moderating effect of health insurance on the association between immigrant length of residence in the US and current and changes in health status, to begin assessing the possible longer-term impacts of being uninsured.
Methods Data for 6,381 legal immigrants who participated in the first wave of the NIS were analyzed [19]. NIS is a nationally representative study of immigrants who were admitted to US legal permanent residence between May and November 2003. The immigrants represent at least 21 countries from six continents. These immigrants reside across all regions of the US, as there are participants from all top 85 Metropolitan Statistical Areas. We focused on participants who immigrated directly from their home country to the US and had complete length of stay information. Duration of residence in the US was estimated by subtracting age at arrival to US from age at interview. Current and change in health status were self-reported, as was insurance status (yes = private or government provided insurance, no = no insurance). Current health status was dichotomized into excellent, very good, or good vs. fair or poor, and change in health status was dichotomized into better or same vs. worse. Separate logistic regression models were fit to estimate the association between duration of residence in the US and current health status and change in health status. All logistic regression models included the following covariates: age at interview, gender, race, years of education, income, marital status, smoking, body mass index, and exercise. We reasoned that the effect of most, if not all, of the covariates included in the regression models (e.g., body mass index, smoking status, and exercise) may vary as a function of access to insurance. For example salubrious effects of exercise may be stronger among uninsured rather than insured respondents. Insured respondents, through their access to health care system, may engage in other health promoting behaviors which would reduce the relative importance of engaging in exercise. Therefore, for ease of interpretation, for each dependent variable we fit two separate logistic regression models, one among the insured and another among the uninsured. This approach is
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equivalent to fitting one regression model that includes interaction terms for each covariate and insurance status. Additionally, sample weights were used in all analyses to account for survey design. Finally, we examined whether receiving preventive measures (mammogram, Pap smear, and prostate exam) in the last year differed by health insurance status as a potential mechanism.
Results Respondent characteristics are described in Table 1. Forty one percent of the sample was Hispanic, 29% were Asian, 11% were Black and 16% were White. The association between length of stay in the US and health status as well as change in health status varied by insurance status (see Table 2). Change in health status was inversely associated with length of stay in the US among both the insured and uninsured with the uninsured having higher odds ratios than the insured. Current health status showed a different association. Among the insured, duration of residence in the US was independent of health status. Conversely, among the uninsured, there was an inverse association between length of stay in the US and current health status. Our findings suggest that negative associations between duration of residence and poor current health and worse health are stronger among uninsured immigrants. During the last year, insured immigrants were almost twice more likely than uninsured immigrants to have received preventive screenings [e.g., Pap smear: Odds Ratios (OR) = 1.98, 95% confidence interval (CI): 1.64, 2.40; prostate exam: OR = 1.83, 95% CI: 1.38, 2.44)].
Discussion To our knowledge, this is the first study to examine moderating effect of access to health insurance on the association between acculturation (measured by length of stay in the US) and current and change in health status. Uninsured immigrants were likely to report poorer health as a function of length of stay in the US than insured immigrants. Health insurance may attenuate the negative effect of longer length of residence in the US on an immigrant’s health. One possible mechanism for this moderating effect may be that insured immigrants have better access to preventive care, as supported in the present study. Others have also found that access to preventive care is higher among insured immigrants [20, 21]. Additionally, health insurance may provide immigrants access to other forms of medical care as well as health information, which may be important to staying healthy.
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Table 1 Weighted distribution of participant characteristics in the study (n = 6,381)a Variable
Table 1 continued Variable
Uninsured Insured P value (n = 4,041) (n = 2,340) Overweight
Age in years; mean (SD)
39.7 (14.1)
36.3 (11.4) P \ .0001 P \ .0001
Change in health status Better, same Worse
3,739 (92.5) 2,030 (86.8) 302 (7.5)
Excellent, very good, good Fair, poor
P = .2614
214 (9.1)
1,797 (44.5)
Female
2,244 (55.5) 1,405 (60.0) P \ .0001
\1 year
1,438 (35.6)
253 (10.8)
1–5 years
1,305 (32.3)
943 (40.3)
6–10 years
470 (11.6)
507 (21.7)
11–15 years
521 (12.9)
400 (17.1)
[15 years
307 (7.6)
237 (10.1)
Asian
1,151 (28.5)
Black
472 (11.7)
Hispanic Multiracial/other White Missing
1,706 (42.2)
465 (19.9)
69 (1.7)
29 (1.3)
12–16
1,077 (26.7)
811 (34.6)
463 (11.4)
505 (21.6)
\$5,000
546 (13.5)
111 (4.7)
$5,000–9,999
211 (5.2)
50 (2.1)
$10,000–24,999
487 (12.1)
231 (9.9)
$25,000–99,999
498 (12.3)
597 (25.5)
35 (0.9)
100 (4.3) P \ .0001
2,862 (70.8) 1,944 (83.1)
Divorced/widowed/ separated
372 (9.2)
136 (5.8)
Never married
807 (20.0)
260 (11.1)
Current smoker
395 (9.8)
236 (10.1)
Past smoker
466 (11.5)
357 (15.2)
Smoking status
P = .0012
3,180 (78.7) 1,747 (74.7)
Body mass index Underweight Normal
944 (23.4)
475 (20.3)
10 (0.2)
5 (0.2)
434 (10.7)
378 (16.2)
P \ .0001 1,986 (49.2) 1,047 (44.7) 145 (3.6)
65 (2.8)
260 (6.4)
118 (5.0)
1,198 (29.7)
722 (30.9)
18 (0.4)
10 (0.4)
Based on those responding to question about change in health status
Based on those responding to question about current health status (n = 6,393)
2,264 (56.0) 1,251 (53.5)
Marital status
Never smoker
Asia Missing
P \ .0001
Income
Married/cohabitating
P = .0009
P \ .0001 2,501 (61.9) 1,024 (43.8)
$100,000?
Sub-Saharan Africa
b
\12
Missing
North Africa and Middle East
920 (39.3)
Years of education
[16
Latin America and Caribbean
a
581 (14.4)
408 (17.4)
North America and Europe
209 (8.9) 26 (1.1)
554 (13.7)
Missing
691 (29.5)
62 (1.5)
75 (3.2)
Region of origin
P \ .0001
Race/ethnicity
233 (5.8)
None (0 time/week)
935 (40.0) P = .0027
Length of stay in US
276 (11.8)
Missing
2,533 (62.7) 1,452 (62.1) Some but not meeting recommended amount (0 \ Exercise \ 3 times/ week)
Gender Male
741 (31.7)
510 (12.6)
Recommended amount (C3 times/week)
3,628 (89.8) 2,126 (90.9) 410 (10.1)
1,223 (30.2)
Obese Exercise
310 (13.2)
Current health statusb
Uninsured Insured P value (n = 4,041) (n = 2,340)
P = .7364 165 (4.1)
102 (4.3)
1,910 (47.3) 1,146 (49.0)
One limitation of this study may be that our sample may not be representative of the general immigrant population. The sample consists only of immigrants who were granted legal permanent residency between May and November 2003, which may exclude some longtime US residents. In fact, 27% of our sample lived in the US for less than a year, and 35% had lived in the US for 1–5 years. However, our sample represents a large number of immigrants from different parts of the world, such as Sub-Saharan Africa, Canada, Asia, South and Central America, and the United Kingdom (See Table 1), whereas previous studies limited their sample to immigrants from certain regions such as from Latin America or Asia only. This study also has several strengths. Little is known about the role of health insurance as a moderator of the association between acculturation and health status in immigrants. Examination of both current health status and change in health status since moving to the US is another important strength of this study, because by examining change in health we have controlled for immigrants’ initial health status, something that has not been accomplished in previous studies and proved to be highly associated with length of stay.
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Table 2 Weighted odds ratios and 95% confidence interval for associations between length of stay in the US and worse health status change or fair or poor current health status, stratified by health insurance coverage Length of stay in US
Age adjusted
Multivariate adjusteda
Age adjusted
Multivariate adjusted No insurance coverage (n = 4,041)
Age adjusted
1.00 2.24 (1.09–4.60)
Total (n = 6,381)
Multivariate adjusted Has insurance coverage (n = 2,340)
Change in health status \1 year 1–5 years
1.00 2.86 (2.01–4.08)
1.00 2.74 (1.92–3.93)
1.00 2.33 (1.52–3.57)
6–10 years
5.19 (3.55–7.59)
5.12 (3.41–7.69)
5.11 (3.16–8.28)
5.44 (3.21–9.21)
3.19 (1.53–6.69)
3.30 (1.49–7.29)
11–15 years
6.15 (4.25–8.92)
6.38 (4.24–9.59)
7.08 (4.53–11.08)
8.27 (4.98–13.72)
3.34 (1.60–6.97)
3.43 (1.53–7.67)
[15 years
6.41 (4.31–9.55)
6.86 (4.39–10.70)
7.02 (4.32–11.40)
8.38 (4.80–14.63)
3.62 (1.68–7.80)
3.51 (1.46–8.42)
Total (n = 6,393)
1.00 2.33 (1.52–3.57)
1.00 2.27 (1.06–4.85)
No insurance coverage (n = 4,046)
Has insurance coverage (n = 2,347)
Current health status \1 year
1.00
1.00
1.00
1.00
1.00
1.00
1–5 years 6–10 years
0.95 (0.73–1.23) 1.66 (1.20–2.30)
1.01 (0.77–1.32) 1.80 (1.26–2.57)
0.90 (0.66–1.22) 1.74 (1.13–2.66)
0.91 (0.67–1.25) 1.78 (1.12–2.80)
0.88 (0.49–1.56) 1.30 (0.70–2.44)
1.09 (0.56–2.10) 1.50 (0.72–3.09)
11–15 years
2.09 (1.56–2.81)
1.77 (1.26–2.47)
2.66 (1.87–3.79)
2.25 (1.50–3.36)
1.19 (0.64–2.22)
1.01 (0.48–2.15)
[1 years
2.78 (2.02–3.83)
2.24 (1.55–3.22)
3.05 (2.07–4.49)
2.51 (1.60–3.94)
2.01 (1.06–3.83)
1.58 (0.71–3.55)
a
Multivariate-adjusted models are adjusted for age at interview, gender, body mass index, income, exercise, marital status, race, smoking, and years of education
Almost two-thirds of our sample is uninsured, a proportion that is higher than estimates for immigrants by US Census Bureau data (34%) [17]. It may be due to the fact that many immigrants work in small businesses which are less likely to offer health insurance. In our study, 67% of immigrant workers are employed in a business with less than 100 people (vs. 36% of the US general population [22]). Additionally, in our sample of employed immigrants (where 57% of them were uninsured), 78% of uninsured worked for an employer with less than 100 employees (vs. 54% of insured). Moreover, the likelihood of receiving employer-sponsored health insurance from small businesses is diminishing. In a survey among a random sample of private and public businesses, the proportion of small businesses with \200 employees offering health insurance dropped from 68 to 59% from 2000 to 2007, compared to business with C200 employees which remained stable at 99% [23]. While the specific reasons for the discrepancy in health insurance coverage between immigrants and natives are not fully understood, numerous sources indicate health insurance may have an effect on the health of immigrants. To combat the decline in health associated with acculturating to the US, immigrants need access to health care. Immigrants may be in the same situation as many other uninsured populations. To help these populations of uninsured, policies can address the gap in coverage for those without insurance and provide affordable alternatives.
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Acknowledgments Shenassa was supported by grant R40MC0 3600–01–00 from the Maternal and Child Health Bureau, Department of Health and Human Services.
References 1. US Census Bureau: United States—Selected characteristics of the native and foreign-born populations. http://factfinder.census.gov (2010). Accessed 19 July 2010. 2. Frisbie WP, Cho Y, Hummer RA. Immigration and the health of Asian and Pacific Islander adults in the United States. Am J Epidemiol. 2001;153:372–80. 3. Jasso G, Massey DS, Rosenzweig, Smith JP. Immigrant health– selectivity and acculturation. In: Anderson NB, Bulatao RA, Cohen B, editors. Critical perspectives on racial and ethnic differences in health in late life. Washington, DC: National Academy Press; 2004. p. 227–66. 4. Vega WA, Amaro H. Latino outlook: good health, uncertain prognosis. Annu Rev Public Health. 1994;15:39–67. 5. Marmot MG, Syme SL. Acculturation and coronary heart disease in Japanese-Americans. Am J Epidemiol. 1976;104:225–47. 6. Berry J, Kim U. Acculturation and mental health. In: Dasen PR, Berry JW, Startorius N, editors. Health and cross-cultural psychology. London: Sage; 1988. 7. Antecol H, Bedard K. Unhealthy assimilation: why do immigrants converge to American health status levels? Demography. 2006;43:337–60. 8. Oza-Frank R, Cunningham SA. The weight of US residence among immigrants: a systematic review. Obes Rev. 2010;11:271–80. 9. McWilliams JM. Health consequences of uninsurance among adults in the United States: recent evidence and implications. Milbank Q. 2009;87:443–94.
J Immigrant Minority Health (2012) 14:345–349 10. Wilper AP, Woolhandler S, Lasser KE, McCormick D, Bor DH, Himmelstein DU Health insurance and mortality in US adults. Am J Public Health. 2009. 11. Ivanov LL, Hu J, Leak A. Immigrant women’s cancer screening behaviors. J Community Health Nurs. 2010;27:32–45. 12. Ponce NA, Chawla N, Babey SH, Gatchell MS, Etzioni DA, Spencer BA, Brown ER, Breen N. Is there a language divide in Pap test use? Med Care. 2006;44:998–1004. 13. Wang JH, Mandelblatt JS, Liang W, Yi B, Ma IJ, Schwartz MD. Knowledge, cultural, and attitudinal barriers to mammography screening among nonadherent immigrant Chinese women: ever versus never screened status. Cancer. 2009;115:4828–38. 14. Somanchi M, Juon HS, Rimal R. Predictors of screening mammography among Asian Indian American women: a cross-sectional study in the Baltimore-Washington metropolitan area. J Womens Health (Larchmt). 2010;19:433–41. 15. Brown WM, Consedine NS, Magai C. Time spent in the United States and breast cancer screening behaviors among ethnically diverse immigrant women: evidence for acculturation? J Immigr Minor Health. 2006;8:347–58. 16. Thamer M, Richard C, Casebeer AW, Ray NF. Health insurance coverage among foreign-born US residents: the impact of race,
349
17. 18.
19. 20.
21.
22. 23.
ethnicity, and length of residence. Am J Public Health. 1997; 87:96–102. US Census Bureau (2008). Selected social characteristics in the United States 2008. Pol LG, Adidam PT, Pol JT. Health insurance status of the adult, nonelderly foreign-born population. J Immigr Health. 2002;4: 103–10. Princeton University: the new immigrant survey. http://nis. princeton.edu/. Accessed 15 Jan 2009. Carrasquillo O, Pati S. The role of health insurance on Pap smear and mammography utilization by immigrants living in the United States. Prev Med. 2004;39:943–50. De Alba I, Hubbell FA, McMullin JM, Sweningson JM, Saitz R. Impact of US citizenship status on cancer screening among immigrant women. J Gen Intern Med. 2005;20:290–6. United States Small Business Administration: Firm size data: US Data. http://www.sba.gov/advo/research/data.html. Accessed 10 Feb. Foundation Kaiser Family. Employer health benefits 2008 annual survey. Menlo Park, CA: Kaiser Family Foundation; 2008.
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