For over 200 years, the United States has been the destination for immigrants with various socioeconomic and cultural backgrounds, arriving from all over the world. Each year, thousands of individuals are awarded legal permanent resident (LPR) status or the "green card," with 946,142 individuals receiving LPR status in 2004 alone (Office of Immigration Statistics, 2006a). Under current immigration law, these immigrants can be classified into four groups--employment or skill based; family reunification; diversity visa program; and other, including refugees and asylees. Thus far, no study has systematically examined variation in health insurance status among these immigrants. We used the New Immigrant Survey data collected in 2003 to examine the health insurance disparities among recent immigrants by their class of immigration. This study used Gelberg, Andersen, and Leake's (2000) framework for vulnerable populations to examine health insurance disparities among the new immigrants. We addressed the following questions: Do immigrants vary by class of immigration? Does the probability of having health insurance vary by class of immigration after adjusting for other factors?
One of the two goals of Healthy People 2010 is to eliminate health disparities among different segments of populations in the United States (U.S. Department of Health and Human Services, 2000). Most national studies examining health disparities of immigrants do not distinguish them by their immigration status, but rather focus on the analysis based on their birth and nativity status. These studies have found the following:
First, immigrants are healthier than natives but their health advantages disappear over time. Foreign-born, especially most recent, immigrants are healthier than the U.S.-born population, supporting notions of positive selection and "healthy immigrant effect" (Antecol & Bedard, 2006; Frisbie, Cho, & Hummer, 2001; Hummer, Rogers, Nam, & LeClere, 1999; Singh & Siahpush, 2001; Stephen, Foote, Hendershot, & Schoenborn, 1994). Over time, however, their original health advantages wane, and they become more vulnerable than natives, especially if they are poor (Antecol & Bedard, 2006; Cho, Frisbie, Hummer, & Rogers, 2004; Frisbie et al., 2001; Lopez-Gongalez, Aravena, & Hummer, 2005; McDonald & Kennedy, 2004; Newbold, 2005).
Second, as a nation, the United States spends less on health care for immigrants. Per capita health care expenditures for immigrants are substantially lower (55 percent lower) than for native-born individuals (Mohanty et al., 2005). Also, expenditures for uninsured and publicly insured immigrants are approximately half those for their U.S.-born counterparts.
Third, immigrants are less likely to have health insurance and to use health care. In 2004, nearly 34 percent of all foreign-born populations, 17 percent of naturalized citizens, and 13 percent of the native populations were uninsured (Carmen, Bernadette, & Cheryl, 2005). Studies examining health care access and utilization among immigrants also show that foreign-born populations have significantly lower access and utilization of health care services than the U.S.-born population (Jacobs et al., 2002; Thamer, Richard, Casebeer, & Ray, 1997; Thamer & Rinehart, 1998). Often, those without health insurance avoid or delay seeking care and buying medications because of cost (Becker, 2004). High prevalence of uninsured people among the foreign-born populations, therefore, presents a major challenge to closing the gap in health disparities.
Fourth, a number of factors are associated with lack of health insurance. As a group, immigrants are less educated, face language barriers, are concentrated in low-wage jobs, earn substantially lower wages, and are less likely to be insured than the native population (Capps, Fix, Passel, Ost, & Perez-Lopez, 2006; Fix & Capps, 2002; Holahan & Brennan, 2000; Jacobs et al., 2002). In particular, younger, low-income adults who have resided in the United States for less than 15 years have the highest uninsurance rates (Holahan & Brennan, 2000; Thamer et al., 1997; Thamer & Rinehart, 1998). Foreign-born women are even more disadvantaged; they are more likely to be uninsured compared with U.S.-born female populations, even when they work full-time year-round (Carrasquillo & Pati, 2004; Weitzman & Berry, 1992). Predictors of health insurance status include demographic characteristics (age, gender, marital status, household size), factors of acculturation (nativity, English language proficiency, length of residency), education, employment, economic status (income, assets), and health conditions.
GAP IN THE LITERATURE
Previous studies examining health insurance status have aggregated all foreign-born populations into one category and compared their health insurance status with that of the native-born population. Also, most probably due to data limitations, these studies have not examined whether there is any variation in health insurance status among legal immigrants. We believe that the class of immigration--that is, the policy immigrants use to attain their green card--is a critical factor that steers some legal immigrants into a more economically vulnerable position than others. Therefore, in this study, we examined whether some legal immigrants are more vulnerable than others in gaining health insurance status. In the following, we briefly review literature on class of immigration, because it may be new to many readers.
According to the U.S. immigration law, all noncitizens are labeled as aliens, a category that is further divided into two groups: nonimmigrants and immigrants. Nonimmigrants are aliens who seek temporary entry to the United States for a specific purpose. They include government officials; tourists (or temporary visitors for pleasure); business travelers who come to the United States to conduct business, but not for employment; temporary workers/trainees (including H-1B computer programmers, seasonal workers, religious workers, artists, athletes, and entertainers) and their families; aliens-in-transit; students; and others (Office of Immigration Statistics, 2007). Illegal or undocumented immigrants are noncitizens who are in violation of the Immigration and Nationality Act of 1952 (P.L. 82-414) by either having entered the United States without having been inspected by the Office of Homeland Security or having overstayed the term of their nonimmigrant visas (Dougherty, Wilson, & Wu, 2005). Illegal immigrants and nonimmigrants have never been eligible to receive public health services except emergency medical assistance, short-term disaster relief, immunizations, treatment, and testing for communicable diseases (Camarota, 2004).
Immigrants, or LPRs, in contrast, are four classes of individuals who have been admitted for permanent residence under the current immigration law (see Table 1). The four main goals of current U.S. immigration policy are to reunify families, admit immigrants with needed skills, increase diversity through the diversity visa program, and admit refugees/asylees (refugees and asylees are eligible to become LPRs after one year of continuous presence in the United States), Amerasians, and others (Office of Immigration Statistics, 2004; Rytina, 2005). Of these four classes, the diversity visa program is the newest addition to the immigration law. Each year since 1995, the federal government has been awarding approximately 50,000 visas to winners of the diversity lottery from a long list of countries (excluding China, Taiwan, Colombia, Dominican Republic, India, Jamaica, Korea, Mexico, the Philippines, Great Britain, Guyana, and Haiti) that are underrepresented (Law, 2002). To apply for the visa lottery, an applicant should have a high school education or two years of work experience in the preceding five years in an occupation that requires two years of training or experience (Immigration Act of 1990, P.L. 101-649; Jefferys, 2005; Law, 2002). The winners of the diversity lottery are granted a visa to enter the United States and are awarded LPR status immediately after their arrival in the United States.
In terms of public benefits to immigrants, the U.S. government allocates funds annually for a comprehensive and coordinated program of resettlement of refugees and asylees (Refugee Act of 1980, P.L. 96-212), who are eligible to receive public assistance, including Medicaid and State Children's Health Insurance Program (SCHIP) (Personal Responsibility and Work Opportunity Reconciliation Act of 1996 [PRWORA], P.L. 104-193). Other LPRs (including family based, employment based, and diversity program) are ineligible to receive federal means-tested benefits, including Medicaid and SCHIE during the first five years of their residence in the United States (PRWORA). After the five-year bar expires for those immigrants who came after August 22, 1996, individual states may decide whether to provide or deny benefits until citizenship is acquired (PRWORA; U.S. General Accounting Office, 1998).
LPRs possess a green card, which allows them to live and work permanently in the United States; after residing in the United States for five years, they are eligible to apply for U.S. citizenship. It is, therefore, important to close the gap in health disparities among these immigrants and to understand whether one group of immigrants is more vulnerable than another.
The most widely used conceptual framework for understanding utilization of health care services, called the "behavioral model of health services use," was originally designed by Andersen, Aday, and Newman in the late 1960s and early 1970s (Aday & Andersen, 1974; Andersen & Newman, 1973). According to this model, health care utilization is a function of people's predisposing characteristics to use health services, factors that enable or impede use of these services, and people's perceived and evaluated need for health...