AMA Journal of Ethics^®

U.S. Immigrants: Current Number and Projections

According to the American Community Survey and U.S. Census, the immigrant population in the U.S. increased by almost 24 percent between 2000 and 2010 [1]. In 2010, approximately 40 million foreign-born individuals resided in the U.S. [1], 53 percent from Latin America (including Mexico and the Caribbean), 28 percent from Asia, 12.5 percent from Europe, 4 percent from Africa, 2 percent from Canada, and 0.5 percent from Oceania. Approximately 44 percent of these immigrants were naturalized U.S. citizens, 26 percent were documented, and 30 percent were undocumented [2]. If present trends continue, there will be approximately 83 million foreign-born people in the U.S. in 2050, representing an increase from 12.5 percent in 2010 to 20 percent in 2050 [3]. In other words, the number of immigrants living in the U.S. is expected to double in size in the next 30 years.

The ACA and Health Care for Immigrants

Immigrants comprise almost 30 percent of the uninsured in the U.S. [1]. Within the foreign-born population, according to 2009 data from the Migration Policy Institute, 52 percent had private health insurance, 15 percent had public health insurance coverage (i.e. Medicare, Medicaid, Children’s Health Insurance Program), and 33 percent were uninsured [4]. By contrast, only 12.5 percent of the native-born population was uninsured in the same year. It is estimated that approximately half of the 33 percent of immigrants who are uninsured are undocumented [2].

The Patient Protection and Affordable Care Act (ACA) will give U.S.-born people and documented immigrants similar entitlements. These policies, however, will benefit those who have been here longer—there will be a 5-year waiting period to receive some benefits [5]. Documented immigrants who have resided in the U.S. for 5 years or less will be subject to the health insurance mandate but will remain ineligible for Medicaid; they are, however, eligible for subsidized participation in the state health insurance exchanges [6]. Undocumented immigrants are excluded from all provisions of the ACA.

The clear beneficiaries of the ACA are the approximately 7 million low- and middle-income documented immigrants who are currently uninsured and have been in the U.S. for more than 5 years [7]. The overall effect of the ACA on newly arrived documented immigrants and undocumented immigrants is currently uncertain. The ACA is more likely to impact undocumented immigrants who currently have health insurance coverage (31 percent of children and 40 percent of the adult (18-64) undocumented immigrant population have employer-provided health coverage [4]) who face the risk of losing it if their employers decide to start providing health insurance through the exchanges, where legal status could be scrutinized more closely. In addition, undocumented immigrants who pay income taxes (using taxpayer identification numbers or false social security numbers) but do not have coverage through their employers may still choose to pay the penalty for not purchasing health insurance coverage, even if they are exempt from the health insurance mandate. They may not want to signal their legal status to the federal government through the Internal Revenue Service, the agency in charge of enforcing the health insurance mandate. Recently arrived documented immigrants and undocumented immigrants who would remain uninsured, however, could potentially benefit from the positive spillover effects of better health care delivery in community clinics and health centers that will receive increased funding through the ACA [6].

Health Care Utilization Among Immigrants

Overall, immigrants are less likely to access, use, and spend on health care than the U.S. native-born population [8-10]. While this can partly be explained by socioeconomic and demographic differences, experts in the field also attribute low health care utilization among immigrants to a phenomenon known as immigrant self-selection [7], one of the most obvious examples of which is the “healthy immigrant effect” [11]: immigrants need to be relatively healthy to leave their countries of origin. Consequently, they are on average healthier than nonimmigrants [11].

Low health care utilization among immigrants can also be related to legal status. One of the main factors that delays seeking care among the undocumented is fear that their legal status will be uncovered if they access the health system [12, 13]. A recent study that compared health care access and utilization among Mexican immigrants found that the undocumented were 27 percent less likely than documented immigrants to have a doctor visit in the previous year and 35 percent less likely to have a usual source of care [5].

Familiarity With the U.S. Health System

Even if immigrants are covered by public or private health plans, coverage does not automatically translate into access. Recently arrived immigrants are often used to health systems that are differently organized and administrated than the U.S. health care system. Differences in care quality, prices, methods of payment, patient expectations, or patient-physician relationship are some of the aspects that immigrants have to become familiar with. Lack of familiarity with the system may contribute to low health care use among the foreign-born. Of the U.S. foreign-born population in 2010, it was estimated that approximately 40 percent entered the country by 1989, 27 percent between 1990 and 1999, and 33 percent in 2000 or later. It is reasonable to expect that immigrants’ experiences in the U.S. health care system differ based on the length of time of U.S. residence, their English proficiency, their knowledge of the American health care system, and similar factors.

What Physicians Should Do to Help

Cultural competency. With the increased diversity of the U.S. population, physicians and other health care professionals have been encouraged to develop competence in providing culturally sensitive care to people with backgrounds other than their own [14, 15].

Cultural competence goes beyond cultural awareness or sensitivity and requires the effective use of skills in cross-cultural situations and community-based health management. Culturally and linguistically appropriate services (CLAS) should be employed to reach out to immigrants and facilitate their integration into the U.S. health care system [16]. Health care professionals, however, need to be careful about not stereotyping and relying on broad generalizations. Cultural competence is by no means a matter of one-size-fits-all treatment.

Physicians and health care personnel should participate actively and regularly in training programs designed to increase cultural awareness, knowledge and skills. This training should start in medical school and continue throughout their careers. For instance, the UCLA health system’s PRIME program trains physicians particularly devoted to serving disadvantaged populations on ways to provide high-quality, culturally sensitive care. Such training models should become more widespread.

Culturally sensitive care and the immigrant integration process are interlinked. Situations can easily arise in which immigrants’ cultural health beliefs and practices clash with the standard of care. Indeed, some health-related beliefs and practices can lead to unhealthy, even fatal, outcomes. This can make care provision difficult. Physicians and other health care personnel should learn how to handle these cases and talk to immigrants about the benefits of high quality care. Healthy behaviors should be encouraged and reinforced to take advantage of the “healthy immigrant effect,” not only in the short term when immigrants arrive in the U.S., but also in the long term.

Language assistance and health information. Language services for immigrants with poor English proficiency should be offered at any point at which they may access the health care system. Health information materials and utilization-related documentation should also be tailored to populations with different levels of English proficiency and cultural approaches to health and health care utilization. Also key for the continual improvement of culturally sensitive quality care standards is the collection and analysis of better data on immigrants’ socioeconomic, epidemiological, and assimilation (e.g., years in the U.S. and English fluency) characteristics. Health care professionals should ensure that this information is consistently collected in health records and management information systems. More important would be to use this information to improve outcomes and health care delivery methods especially tailored to immigrants.

Organizational openness to cultural diversity. A culturally diverse workforce can also facilitate the administration of quality and culturally sensitive care to immigrants. Recruiting, retaining, and promoting a culturally diverse workforce can encourage the dissemination of open, multicultural approaches to delivering health care. The best way of approaching this goal is continued support and expansion of residency and fellowship programs for and mentorship of members of groups historically underrepresented in health care.

Health care organizations should also develop effective outreach approaches to integrate immigrants into the U.S. health care system. Developing partnerships with organizations in the communities they serve and engaging with hometown associations (i.e., those organizations formed in the U.S. by immigrants from the same towns or regions) represent effective ways of facilitating this process. Coordination with traditional healers and other alternative practitioners should be considered to ensure continuity of care and avoid complications.

Conclusions: The Role of Health Care Providers in Immigrant Assimilation

The increased diversity of the immigrant population in the U.S. in terms of countries of origin, length of stay, and legal status emphasizes the need for cross-cultural adaptation of care and the role of health care providers in facilitating the integration of the foreign-born population to the U.S. health care system. “Integration” is generally described as a process that helps immigrants achieve self-sufficiency, political and civic involvement, and social inclusion in their new countries [17].

Immigrants are self-selected, but the longer they stay in the U.S. the more they start to resemble the U.S. native population in several measures ranging from income to health expenditures and utilization [7]. Most immigrants assimilate after a few generations. Evidence shows that recently arrived immigrants to the U.S. will not be the exception [18]. Physicians and other health care professionals should become more knowledgeable about the different stages of this transition process so they can facilitate better integration of immigrants into the health care system.