The United States is a nation of immigrants where 1 in 7 U.S. residents are foreign-born.  When including children born in the U.S. to immigrant parents, this accounts for nearly a third of the U.S. population.  Globally, international migration is also rising exponentially over time, with over 281 million people living outside their birth countries. The cause for this increase stems from a multitude of reasons, including natural disasters, escaping imminent harm, or seeking better employment opportunities.    

Although the immigrant population is growing, there is still much we do not understand about their health care outcomes, particularly why they utilize less health care than their native counterparts. Despite the phenomenon of newly immigrated U.S. residents being healthier than U.S. born residents, studies have found this advantage fades over time. This is across chronic diseases, including cancers. The COVID-19 pandemic made this plain as immigrants fared worse than their native-born counterparts in the U.S. and Canada. So why are they not seeking or accessing necessary care?

This could be for a multitude of reasons, including language barriers, mistrust of the health care system, fear of racial or cultural stigma, low health literacy, and financial barriers to care. These barriers exacerbate the difficulties of trying to navigate a health care system that was not built for foreign-born patients in the first place. For example, previous research has shown that non-white immigrants and those with limited English proficiency face higher disadvantages and lack of health care coverage compared to their white English-speaking counterparts. There is a great deal we as health services researchers must still work to understand about alleviating these barriers to seeking care, and that starts with one word: data.

Too often, the U.S. immigrant population is treated as monolith when these vibrant communities are far from homogeneous. More recently, immigrants are most likely coming from India, China, Mexico, and the Philippines among many other countries. These nations encompass dozens of languages, with vastly different cultural practices and norms. Yet, there is still so much we do not know or understand about immigrant subpopulations.

Calls for better race, ethnicity and origin data are becoming more frequent as researchers are forced to either extrapolate from limited federal race data or collect their own. The Biden Administration is set to update the Office of Management and Budget (OMB) standards for collecting race and ethnicity data which could be a step towards a more comprehensive approach that “reflect the diversity of the American people.” Through these efforts and accompanying “country of origin” questions, we can add to the sparse data repository for improving immigrant health.  

With improved data comes a responsibility to these populations, as the stigma towards immigrant populations is still extremely high. Most electronic health records, for example, do not collect immigration status or country of origin. There is justification in this though, given the persecution many face based on their immigration status. The AMA has spoken against explicit documentation of patient immigration status for fear of what repercussions there could be for those patients. There is a real fear for what may happen to those seeking health care who are undocumented, as anti-immigrant sentiment is pervasive. A physician’s credo to first “do no harm” includes minimizing opportunities for possible discrimination against their patients. Immigration and Customs Enforcement has also been known to frequent emergency rooms and clinics seeking undocumented individuals, or even subpoena medical records, further threatening their safety. Though the lack of immigration status in the EHR is a necessary obstruction, it is one of many examples of a large gap in understanding the impact of access to care on foreign-born patients.

For these reasons, researchers must take precautions when analyzing such sensitive information. This could include deidentifying study data, encrypting files, and building a well-trained study team. Whether from empirically collected data or federally aggregated datasets, the threat of additional scrutiny due to stigma is real.  To ensure the protection of those at risk, the urging for robust data collection must also be accompanied by stringent privacy and data safety protocols.

There is no one-size-fits-all approach to immigrant health, but we are still far from providing accessible, equitable, and affordable care to these populations.  If we aim to better understand the health issues impacting immigrant subpopulations, we need data to do so. There are too many gaps in our understanding of how and why these populations seek care and what barriers they may face. Health systems and communities must determine the best ways to provide care as this group grows--and ages—over time.

Julie Ressalam, M.P.H.

Doctoral Student - University of Colorado School of Public Health

Julie Ressalam is AcademyHealth’s Spring 2023 Health Policy Fellow Read Bio

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