Access to Health Care for
Adult Latino Immigrants:
Are Lack of Health Care
Coverage and Discrimination
Barriers to Accessing Care?
Claire Olivier and Hana Tylova-Stein
PH212C: Migration and Health, 2012
Today’s
Outline
1. Andersen’s Behavioral Model of Access to
Health Care
2. Is Lack of Health Care Coverage a Barrier to
Accessing Care?
3. Is Discrimination a Barrier to Accessing Care?
1. Andersen’s Behavioral Model of
Access to Health Care
Health care access and utilization can be explained
as a function of 3 indicators:
 Predisposing characteristics – individuals'
predisposition to access and use services
 Enabling resources – factors that enable or impede
access to and use of services
 Need variables – individuals' need for services
Predisposing Characteristics
 Demographic factors include age and gender.
 Social structure includes ethnicity, culture, education,
social networks, and occupational status that determine
individuals’ status in the community and their ability to
cope with problems.
 Health beliefs “about health and health services that
might influence subsequent perceptions of need and
use of health services.”
Source: Andersen, 1995
Enabling Resources
 Community resources include availability and ease of
access to health personnel and health care facilities,
and regular sources of care.
 Personal resources include health insurance, income,
and immigration status.
Source: Andersen, 1995
Need Variables
 Include:





General health
Severity of symptoms
Level of functioning
Experience of symptoms
Perception of needing help
Source: Andersen, 1995
Equitable vs. Inequitable Access
Source: Andersen, 1995
Focus of Today’s Presentation
We will focus on enabling resources that impede
health care access and utilization:
 Lack of health care coverage
 Discrimination
2. Is Lack of Health
Care Coverage a
Barrier to Accessing
Care Among LowIncome Latino
Adults?
Health Care Coverage: Outline
 Review of literature on health care coverage and
the lack of coverage as a barrier to care
 Available health care coverage for low-income
immigrant adults
 Today
 Under Health Care Reform
 Policy implications
 Final thoughts
Rates of Health Insurance Coverage
 Latino adults have the lowest rates of health insurance
coverage among all ethnic groups.
 The uninsured rate is 43.1% among Hispanic adults
(28.8% for native-born and 56.4% for foreign-born),
compared to 15.6% for White, 26.8% for Black, and
19.4% for Asian adults.
 Mexican immigrants have lower rates of health
insurance coverage than other immigrant and white
U.S.-born populations (Figure 1).
Source: Pew Hispanic Center, 2010; CONAPO, 2010
Figure 1: Immigrant Population (from Mexico and Other regions) and
White U.S.-Born Population without Medical Health Insurance in the
United States, 2007
Factors Associated with Health
Care Coverage
 Among undocumented Mexican immigrant adults,
living in a residence with fewer other adults, linguistic
acculturation, higher levels of formal income, social
support, and poor health were associated with health
insurance coverage.
 Having health insurance coverage was one of the
variables associated with access to a regular health
care provider.
Source: Nandi et al., 2008
Barriers to Health Care Coverage
 Lack of employer-sponsored insurance (ESI)
 Immigration status
 Other factors such as:
 Low English proficiency
 High cost of health care coverage
Lack of ESI: A Barrier
to Health Coverage
 Noncitizens are the least likely to have employersponsored insurance, followed by naturalized citizens
and the U.S.-born.
 Mexican immigrants tend to engage primarily in poorly
paid occupations that do not provide ESI.
 85% of newly arrived and 70% of long-term Mexican
workers are concentrated in unskilled service
occupations, manufacturing, and construction.
Source: Derose et al., 2009; CONAPO, 2010
Immigration Status: A Barrier
to Health Coverage and Care
 Immigration status affects immigrants’ ability to obtain
public health care coverage designed for low-income
families.
 The lack of health insurance is a common reason for
limited access and use of health care services for
prevention, diagnosis, and treatment.
Source: Derose et al., 2009; CONAPO, 2010
Immigration Status: A Barrier to
Obtaining Coverage and Care Cont.
 Immigrants, especially noncitizens and the
undocumented, are less likely to have health insurance
and regular sources of care, and to use services than
the U.S. born populations.
 The non-naturalized Mexican population with low
incomes displays the lowest rates of health insurance
coverage when compared to other immigrant
populations (Figure 2).
Source: Derose et al., 2009; CONAPO, 2010
Figure 2: Immigrant Population (from Mexico and Other Regions)
with Medical Insurance by Citizenship Status in the United
States, 2007
Other Barriers
to Health Coverage
The main barriers to obtaining health care coverage:
 Undocumented status in the US, low English
proficiency, and inability to navigate the health care
system among low-income, newly arrived Hispanic
immigrant adults.
 High cost of health insurance, lack of required
documents, and confusion about eligibility among
those who lived in the US for several years.
Source: Cristancho et al., 2008
Research Recommendations
 Growing body of literature has examined barriers to
obtaining health care coverage, as well as how lack of
health coverage is a barrier to care.
 However, more research focusing on differences
among immigrant subgroups is necessary to
understand the patterns for specific groups.
Coverage for LowIncome Immigrant
Adults
Today and Under
Health Care Reform
 Federal/State Health Care Coverage
 Medi-Cal: California’s Medicaid
 Local Initiatives to Improve Access to Care
 Healthy San Francisco
 Health Care Reform
Federal/State Health Coverage:
Medicaid Program
 Provides comprehensive health care services to
certain low-income groups.
 Operated jointly by federal and state governments,
with federal government sharing the cost.
 Administered by states that define eligibility within
broad federal guidelines, determining type of benefits,
amount, duration, and scope of service.
Source: Kaiser Commission, 2004; National Health Law Program, 2000
Medi-Cal: California’s Medicaid
 As required of ALL states, California covers:
 Basic package of health care services: hospital care,
nursing home care, physician services, laboratory and xray services, family planning, health center and rural
health center services, nurse midwife, and nurse
practitioner services.
 Comprehensive children’s health benefit package known
as Early and Periodic Screening, Diagnosis, and
Treatment (EPSDT) for children under age 21.
 California also provides: drug prescriptions, vision,
dental, mental health care and more.
Source: Anthem Blue Cross, 2011; National Health Law Program, 2000
Medi-Cal: Eligible Groups
 Medi-Cal covers ALL mandatory and optional
categorically needy groups, for example:







Low-income families with dependent children
SSI recipients
Infants born to Medicaid-eligible women
Children 1-18
Pregnant women
Poor persons who are aged, blind, and disabled
Low-income persons who have been screened for breast
and/or cervical cancer
Source: National Health Law Program, 2000 & 2008
Is Immigration Status a Barrier to
Obtaining Medicaid?
YES It Is…
Federal government prevents states from using federal
funds for Medicaid to cover:
 Immigrants who are lawful residents who have not lived in
the United States for more than 5 years.
 Legal immigrants who have resided in the United States for
more than five years who are PRUCOL.
 Undocumented immigrants.
All legal and illegal immigrants are eligible for emergency
Medicaid (if meeting other eligibility criteria), and for
emergency room and stabilization.
Source: Kaiser Commission, 2004; National Health Law Program, 2000
California’s Response?
Since federal law does not prohibit states or localities
from using their own funds to provide health
insurance coverage to immigrants (legal or
undocumented), California has used state-only
funds to address this gap for low-income immigrants.
Who is Covered by Medi-Cal?
 Low-income lawful immigrants regardless of their date
of entry and PRUCOL immigrants qualify for full-scope
Medi-Cal.
 Low-income immigrants awaiting legal status, who live
in California and plan to stay, qualify for emergency
and some other Medi-Cal health services.
Source: Kaiser Commission, 2004; National Health Law Program, 2008
From Federal/State Health Coverage
to Local Initiatives to Improve
Access to Care for Immigrants

San Francisco’s Efforts
to Improve Access to Care
San Francisco enacted several policy measures to
encourage provision of public services and benefits
regardless of immigration status:
 San Francisco’s Sanctuary Policy, also called “limited
cooperation,” fights against discrimination based on
immigration status.
 Municipal ID Ordinance offers a municipal identification
card to all city residents regardless of immigration status.
 Healthy San Francisco
Source: Marrow, 2011
Healthy San Francisco (HSF)
Provides
universal health care
to all uninsured SF
resident adults (18-65)
who do not qualify for
other forms of federal
or state public
insurance
HSF: Basic and Ongoing
Medical Services
 Provided regardless of immigration status,
employment status, or pre-existing medical condition.
 Include primary and specialty care, inpatient care,
diagnostic services, mental health services, and
prescription drugs.
 Services are provided by 29 participating clinics and 5
local hospitals.
Source: Kaiser Commission, 2009
HSF: Funding
 It is funded by city funds, some federal funds, and
payments from employers.
 Participation is free if residents’ incomes fall below
the federal poverty line; otherwise clients pay
quarterly participation cost and point-of-service fees
based on their income (Figure 3).
Source: Kaiser Commission, 2009
Figure 3: HSF Participant Cost Sharing
Source: Kaiser Commission, 2009
Deserving to a Point: Unauthorized
Immigrants in San Francisco’s
Universal Access Healthcare Model
Marrow interviewed
36 providers and staff
from San Francisco’s
public safety net to
examine how such
inclusive local
policies work.
Universal Access Healthcare Model:
Benefits
The SF’s inclusive policies:
 Reinforce public safety-net providers’ “views of
unauthorized immigrants as patients morally
deserving of equal care.”
 Help them translate these views into actual behaviors
by providing them with financial resources.
Source: Marrow, 2011
Universal Access Healthcare Model:
Disadvantages
 Formal barriers:
 Services offered are limited to those provided by
participating healthcare institutions.
 A range of specialty services is not covered.
 Hidden bureaucratic barriers:
 Hospitals’ complicated registration process.
 Clinics’ overburdened phone lines.
 Fear of deportation resulting from the need to submit
proof of SF residency, low income, and a denial from
Medi-Cal.
Source: Marrow, 2011
Looking Ahead: Health Care Reform
Coverage Options
Under the Affordable
Care Act (ACA)
Beginning in 2014:
 Medicaid will expand to cover nearly all individuals with
incomes up to 133% of poverty.
 Individuals without access to affordable employer insurance
will be able to buy insurance through new health insurance
exchanges.
 Those with incomes up to 400% of poverty will be eligible for
tax credits to help pay for the coverage.
Source: Kaiser Commission, 2012
ACA: Immigrant Eligibility Restrictions
Source: Kaiser Commission, 2012
ACA: Impact on Latino Immigrants
 It will increase access to preventative and primary care,
and improve efforts to fight chronic disease.
 However, it may negatively impact undocumented
immigrants.
 With the flood of new immigrants with health care
coverage, it may be difficult for safety-net providers to
keep their doors open for undocumented immigrants.
Policy Implications
 Although state and local governments play a key role in
expanding access to care for all immigrants, and the
ACA will be the first step towards reducing disparities in
access to health care coverage, barriers for certain
immigrants will remain.
 We need to encourage:
 Cooperation between all levels of government to ensure
adequate funding, and to reduce eligibility restrictions for
Medicaid so as to offer universal health care.
 Public-private initiatives and bi-national health insurance
options that might help ensure better coverage of all
immigrants.
Final Thoughts
 Find out more on bSpace about federal, state, and local
efforts to provide health care coverage to children from
low-income families.
 “Providing insurance coverage to all immigrants would
no doubt reduce access disparities, but given that a
number of studies still found reduced use of services
for noncitizens and persons with limited English
proficiency even after adjusting for insurance status,
other barriers associated with being an immigrant
remain.”
Source: Derose et al., 2009
Be back in 5-7minutes please 
3. Discrimination As a Barrier to
Accessing Health Care: Outline
I. Literature Review Exploring Discrimination as an Impacting
Factor in Accessing Health Care for Immigrants
II. Summary
III. Limitations of Research Articles
IV. A Look at Health Care Providers
V. News Article Re: Healthcare Discrimination & Video Clip
VI. Recommendations for Research and Policy
VII. Questions
I. Literature Review Exploring Discrimination
as an Impacting Factor in Accessing Health
Care for Immigrants
 Questions that led research:
 Is it a barrier to health care for immigrants?
 How do immigrants experience discrimination?
 Does legal status of immigrants matter?
 Are there differences between urban and rural reports
of discrimination?
 Lit review includes research from various locations
within the U.S. Focusing on Latino Adults
First Study
• Access to and use of health services among
Mexican born undocumented immigrants living
in New York City in 2004
• 431 immigrants interviewed, age 18+, 299 were
men, 130 women
Source: Nandi et al., 2008
 One set of questions looked at enabling factors, such
as discrimination that could impede their use of health
care services.
 Participants were asked if they had ever been
discriminated against, prevented from doing something,
hassled, or made to feel inferior because of age, race,
language, immigrant status, gender, sexual orientation,
poverty, drug use, having been in jail or prison, religion,
mental illness, physical illness or disability, or other
reasons.
 171 reported no discrimination (40.6%). Those
experiencing discrimination experienced as:
 Related to race (12.4%),
 Related to language (25.2%),
 Immigrant status (15.9)
 Other forms of discrimination (5.59).
No Discrimination
Access to
Health
Insurance
Access to a
Regular
Provider
Receipt of Care
in an Emergency
Dept
13.0%
42.9%
13.0%
9.6%
35.3%
9.8%
7.6%
24.8%
11.5%
7.6%
43.3%
16.9%
16%
24%
20%
40.6%
Race
12.4%
Language
25.2%
Status
15.9%
Other
16%
Second Study
CA study of immigrant perceptions of discrimination
in health care
 This study asks…
 Whether foreign-born persons are more likely to report
discrimination in healthcare than U.S.-born persons in
the same race/ethnic group,
 whether the immigration effect varies by race/ethnicity,
and
 whether the immigration effect is “explained” by sociodemographic factors.
Source: Lauderdale et al, 2008
 The authors conducted a cross-sectional analysis of
the 2003 California Health Interview Survey consisting
of 42,044 adult respondents.
 18+, average age was late 30’s to early 40’s
 Approximately 50% male/female.
 They did not inquire about immigration status, only if
the person was foreign born.
 Overall, 24.8% of respondents were foreign-born, but
foreign-born % ranged by race/ethnicity from 5.8% of
African American/blacks, 64.5% Latinos, 79.2% of
Asians.
 Access to care was represented by health insurance
and usual source of care
Results
 Foreign born effect was not significant for blacks and
native Americans nor was it statistically different from
the foreign born effect for whites.
 Among Asians and Latinos, foreign birth significantly
increases reports of discrimination.
 Better SES is only weakly protective for the foreignborn.
Third Study: Health Care Access, Use of
Services, and Experiences Among
Undocumented Mexicans and Other Latinos
 Utilized the 2003 California Health Interview Survey data
 Compared access to health care, use of services, and
health care experiences for Mexicans and other Latinos by
citizenship and immigrant authorization status.
 Study looked at Mexicans as one group, Other Latinos as
the other group
 Within those two groups compared status: U.S. born,
Naturalized, Green Card, Undocumented.
Source: Ortega et al., 2007
Results
 The undocumented immigrants in both groups
(Mexicans and other Latinos) constituted the highest
proportions of those having difficulty understanding
their physicians during their last visit
AND
 thinking that they would get better care if they were of a
different race or ethnicity.
Fourth Study
Listening to Rural Hispanic Immigrants in the
Midwest: A Community-Based Participatory
Assessment of Major Barriers to Health Care Access
and Use (2008)
 Study with immigrants in Midwest, 3 rural communities
in Illinois
 Used focused small group discussion.
 181 participants, 18+
Source: Cristancho et al., 2008
 Main question: What are the main barriers you
encounter when accessing and utilizing health care
services in your community?
 Discrimination was one of the issues consistently
mentioned.
 Medicaid Discrimination
“While taking my treatment for tuberculosis, I was advised
to take contraceptive pills. Then, I got pregnant. The
doctor never told me then that treatment for tuberculosis
might make the contraceptive pills less effective, as was
later explained to me. I was not prepared to get pregnant
again because my husband didn’t have a good job and I
needed to start working to help my family. . . .
I ended up feeling very sick during my pregnancy and I
was told that there was a chance that my baby could be
born with some malformations. I suffered a lot because I
didn’t know what was going to happen. Thank God, my
baby was born normal and healthy; however, I never got
an apology from my doctor, so how can I trust him again?
If I would have had good health insurance, this would
have never happened.”
Lack of insurance attributed as a cause of
discrimination and negligence, which could lead to
more serious health problems that could’ve been
prevented with effective care.
 “In some clinics and health care centers, they make us
Latinos wait too long. It is common to wait for two or
three hours to get assistance and the situation is worse
if you don’t have health insurance. It is evident that they
prefer Americans . . . gringos go first regardless of how
urgently we need a solution to our problems.”
 Discrimination in form of judgment from medical interpreters.
 Lack of available, quality medical interpretation
 May need to rely on clerical staff for interpretation
 Problematic due to:
Lack of reliable information
Knowing if information has been translated correctly
Privacy concerns
 “ Medical interpreters are not fair. . . . They lack
professional ethics. They just assist people with whom
they have a good relationship. Medical interpreters are
in charge of deciding who gets discounts and what type
of discounts they get. If you don’t have a good
relationship with them, they don’t give you any
discount. Some people give them some presents like
tamales and fruits in order to get better access to
health care services and it works.”
II. Summary
 Further research included an article that was itself a lit
review examining immigrant, health care access,
quality and cost.
 Authors conducted a systematic search for post-1996
to 2008, population-based studies of immigrants and
healthcare. Of the 1,559 articles identified, 67 met
study criteria of which 77% examined access, 27%
quality, and 6% cost.
Source: Derose et al., 2009
 Foreign born more likely to report feeling discriminated
against in health care, specifically those who are:
non white, noncitizens, and have limited English
proficiency.
 Health insurance status can impact reports of
discrimination.
Source: Derose et al., 2009
 Undocumented Latinos and those with a green card
were more likely to feel that they would get better care
in of a different race, than U.S. born Latinos.
 Parents who do not speak English well or who have
noncitizen children are more likely to report being
discriminated against in seeking care for their children
than parents who speak English.
Source: Derose et al., 2009
III. Limitations of Research Articles
 Term discrimination is subjective
 Possible that undocumented immigrants may
underreport key areas of concern
 Limited by self reported data
 Types of sampling used (venue)
Limitation Cont.
 Heterogeneity may make the experience of being an
immigrant or nonwhite different in California than the
rest of the country
 Studies tended to focus on general access to health
care versus specialty practices
 Due to not wanting to raise fear re: deportation,
researchers could be hesitant or unwilling to ask for
legal status
IV. A Look at Health Care Providers
Class Brainstorm
Potential reasons providers discriminate
How do they discriminate?
Paved With Good Intentions: Public Health &
Human Service Providers Contributions to
Racial Disparities in Health.
 Providers may influence help seekers views of themselves
and their relation to the world.
 Providers may consciously or unconsciously re-enforce and
reflect societal messages.
 Non-Whites have been found to be at significantly higher
risk for inadequate or no pain assessment or pain control
than their White counterparts in a variety of situations,
including emergency department treatment of long bone
fractures,'" nonmalignant pain in a nursing home,'"
treatments for cancer-related (in this case the study focused
on doctors and nurses).
Source: van Ryn et al., 2003
 African Americans and Latinos have been found to be
less likely than Whites to receive guideline-adherent
treatment and follow-up (which could affect their
continued utilization).
 Cardiac patients race and ethnicity and SES negatively
influenced physicians ratings of their personality,
education, intelligence, career demands and likely
treatment adherence.
Source: van Ryn et al., 2003
Class Brainstorm Part II
“There is substantial evidence that when people mentally assign
individuals to a particular class or group, they unconsciously
automatically assign the characteristics of that group to the individual
in question, a process referred to as stereotype application…
it is both difficult and painful for many of us to accept the massive
evidence that social categories automatically and unconsciously
influence the way we perceive people and in turn, influence the way
in which we interpret their behavior and behave towards them.
However given that this type of strategy is common to all humans in
all cultures and is more likely to be used in situations that tax
cognitive resources (eg time pressure), the expectation that providers
will be immune is unrealistic.”
Source: van Ryn et al., 2003
 What do you think of this quote?
 If you agree, what do you think providers at any level,
clerical to doctors, etc., can do to address this
concern?
Deserving to a point: San
Francisco Providers’
Perspectives
Do health care providers support San
Francisco’s inclusive policies?
Source: Marrow, 2011
 Interviews were conducted with 36 primary care
providers and staff working in San Francisco’s public
safety net between May and September 2009
 Utilized combination of purposive and snowball
sampling.
 Included a range of providers, 54 respondents
Source: Marrow, 2011
Results
 Variation existed among participants, yet could still be
distinguished from general American public and
conservative health care providers.
 Inclusive policy sanctions providers who disagree city’s
inclusive local policy context
 Clerical worker: policy of treating everyone tempers
providers’ fiscal resentment.
 Health worker union: “undocumented immigrants
shouldn’t be here,” but “kids should get help.”
 Medical evaluation assistant: everyone who is sick has
right to health, but not 100% supportive of
undocumented immigrants having equal access
 Sanctuary ordinance encourages providers to look
beyond patients’ legal statuses.
 Inclusive policy allows public providers to not worry
about direct financial cost
V. News Article Re: Healthcare
Discrimination & Video Clip
“Three immigrants with green cards in N.J. file health
care discrimination lawsuit” June 29, 2010
Source: Diamant, 2010
 Stated it is discriminating against them by removing
them from state-subsidized health care due to their
immigration status.
 The lawsuit seeks to prevent the state Department of
Human Services from instituting planned budget cuts
that would remove the plaintiffs — and about 12,000
other non-citizens — from New Jersey FamilyCare, the
state’s insurance plan for low-income families.
Source: Diamant, 2010
 Two of the plaintiffs are from Ecuador, the third from
Jamaica.
 They have been legal permanent residents less than
five years, meaning they will lose their FamilyCare
benefits.
 Family cannot afford health care without subsidies;
Manual Guaman, a cook, is sole provider.
Source: Diamant, 2010
 Sen. Joe Vitale (D-Middlesex), who opposed the FamilyCare
cuts, said he supports the suit.
 "These men and women work hard, play by the rules, and
are on the path to citizenship that we have established and
that they honor," said Vitale, a longtime proponent of
FamilyCare. "To kick the overwhelming majority of them to
the curb and deny proper health care upon which they have
come to depend, is morally wrong and fiscally imprudent.“
Source: Diamant, 2010
 Video Clip:
http://www.nj.com/news/index.ssf/2010/06/three_immigrants
_with_green_ca.html
VI. Recommendations for
Research & Policy
 Immigration status should be included in research re:
discrimination in health care as it is a key predictor of
perceived discrimination among Asians and Latinos.
 Outreach efforts through sources such as trusted
community-based organizations are important to
decrease concerns regarding how enrollment in
publicly funded insurance programs might affect
residency and citizenship applications.
Source: Lauderdale et al., 2006; Derose et al., 2009
 Policies to improve language services should require
Medicaid to cover access to an interpreter in each state
 Federal and/or state policies that focus specifically on
immigrants in new destinations
 Include discrimination training for medical interpreters,
especially in rural areas.
Source: Derose et al., 2009; Cristancho et al., 2008
Thank you for your
attention!
Any Questions ???
References
 Andersen, R. M. (1995). Revisiting the behavioral model and access to
medical care: Does it matter? Journal of Health and Social Behavior,
36(1), 1-10.
 Anthem Blue Cross Foundation. (2011). Finding health care coverage in
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 Consejo Nacional de Poblacion (CONAPO). (2008). Migration and health:
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 Cristancho, S., Garces, M. D., Peters, K. E., & Mueller, B. C. (2008).
Listening to rural Hispanic immigrants in the Midwest: A community-based
participatory assessment of major barriers to health care access and use.
Qualitative Health Research, 18(5), 633-646.
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 Diamant, J. (2010). Three immigrants with green cards in N.J. file health
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29, 2010 from
http://www.nj.com/news/index.ssf/2010/06/three_immigrants_with_green_
ca.html
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 Kaiser Commission on Medicaid and the Uninsured. (2009). Key facts on
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 Kaiser Commission on Medicaid and the Uninsured. (2012). Key facts on
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