How Immigrant Status is a Determinant of Health for Asian Americans, Native Hawaiians and Pacific Islanders

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Editor’s Note: PolicyLab had the pleasure of hearing from Kathy Ko Chin, president and chief executive officer of the Asian & Pacific Islander American Health Forum, on leveraging Medicaid and the Children’s Health Insurance Program as high-quality programs for all youth at our event during the American Public Health Association Annual Conference in November 2019. Below is a summary of her remarks.

This is part of our social determinants of health blog post series, which features content from PolicyLab experts and guest authors. We invite you to check back in for new posts or to follow along for updates on Twitter at @PolicyLabCHOP.

Did you know Asian Americans, Native Hawaiians and Pacific Islanders (AAs and NHPIs) are the fastest growing racial/ethnic groups in the U.S, representing approximately 24 million people, nearly 100 different ethnic groups, and over 250 languages and dialects? Within this growing population, it’s important to note that AAs and NHPIs vary greatly in their demographic and socio-economic characteristics. For many low- and middle-income AA and NHPI children and families, public insurance programs allow them to obtain health insurance coverage, with nearly 17% of AAs and 28% of NHPIs relying on Medicaid. These programs are particularly important for certain AA and NHPI subgroups with high rates of poverty such as Burmese, Bhutanese and Marshallese

Due in part to Medicaid expansion under the Affordable Care Act (ACA), from 2013 to 2016, uninsured rates were cut in half for AAs. However, this trend is changing in different parts of the country. The recent release of 2018 American Community Survey data by the U.S. Census Bureau shows that seven states have an uninsured rate of 10% or greater for AAs.  Many AAs rely on Medicaid coverage, but challenges exist to accessing adequate health care services.

Immigration Status is a Social Determinant of Health

As a largely immigrant community, current restrictions on immigrant access to health care services and programs greatly impact AAs and NHPIs. For example, legal permanent residents and other categories of immigrants must wait five years before receiving Medicaid coverage. Because of these restrictions, immigration and residency status is one of the greatest determinants of health status and health insurance coverage.

Additionally, according to the Kaiser Family Foundation, the uninsured rate for lawfully present immigrant children is about 20%, compared to 4% for citizen children with citizen parents. These statistics suggest that there is a disproportionate impact on communities with larger percentages of legal permanent residents.

AAs and NHPIs are not a homogenous group, and their immigration statuses are just as diverse. I would like to highlight two key barriers we face to improving the health of this vibrant community: the public charge rule and the lack of data on ethnic groups.

Public Charge Threatens Immigrants’ Health

In October 2018, the Trump administration proposed to widen the definition of “public charge,” which is a term used to identify an individual who is likely to become primarily dependent on government public benefit programs. The proposal would add non-cash programs like the Supplemental Nutrition Assistance Program and Medicaid to a public charge determination, which would create a barrier to health coverage for 1.4 million AAs and Pacific Islanders (PIs). The rule is now slated to go into full effect on Feb. 24, 2020, in all states, except the state of Illinois, where the rule is blocked by an injunction. In the meantime, there are several cases challenging the rule in federal court nationwide that have not yet been decided.

We have already heard from our community partners across the country how AAs and PIs, even those with U.S. born children, are declining to enroll or are disenrolling from health care programs like Medicaid and the Children’s Health Insurance Program out of the shear fear that their use of these health services will impact their immigration status. Additionally, in a Kaiser Family Foundation survey, nearly half of community health centers said immigrant patients were refusing to enroll in Medicaid while nearly one-third of centers said children of immigrant parents were being removed from such programs.

Given the current anti-immigrant political climate and proposed policies, there are real consequences that have led to a decrease in the number of insured children, impacting potentially the health and well-being of this new generation of immigrant children and families.

Data Disaggregation is Key to Tackling Health Care Disparities (and Opportunities)

By looking at ethnic subgroup data, or specific racial/ethnic categories that describe individuals, we are able to effectively address health disparities facing children and families in AA and NHPI communities. Each subgroup has unique demographic and socio-economic characteristics such as income, poverty and limited English proficiency that impacts health status and access to care.

One example of the value of using ethnic subgroup (or “disaggregated”) data was through our campaign to enroll AAs and NHPIs in health insurance ahead of the first year of ACA open enrollment. When looking at AAs as a whole, it looks as if the community is healthy with a low rate of uninsurance. However, this changes once we disaggregated the data and looked at the unique characteristics of ethnic subgroups.

In the Korean American community, which had an uninsured rate of over 20%, we found that many of the unenrolled were employed in small businesses that did not offer health insurance.

We sent targeted, in-language material about their coverage options provided through the ACA, and were able to significantly increase their health insurance enrollment. In fact, by 2016, Korean American uninsured rates were cut to under 10%. We were able to reduce their uninsured rates by over 50% because we found a solution to a problem that was previously invisible without disaggregated data.

We’re continuing to fight for better and more accurate health data about our community. Because AAs and NHPIs are often lumped together as a mega group, some of the most vulnerable groups have become invisible.

Legislative Advocacy is Another Approach to Tackling Health Disparities

Despite the barriers that immigrant communities like AAs and NHPIs face, there are current opportunities for change. For example, the Health Equity and Accountability Act (HEAA) is a comprehensive bill that lays out a roadmap to addressing health disparities among racial and ethnic minorities, the LGBTQ community, rural populations and socioeconomically disadvantaged populations. More specifically, the bill aims to improve the collection and reporting of health data, enhance linguistically appropriate and culturally competent health care services, promote programs to improve health for women and children, and dedicate resources to address the social determinants of health. HEAA also includes several provisions to improve maternity health outcomes and increase diversity in the maternity health care profession. Additionally, the bill lays out a bold blueprint to deliver on the idea that quality, affordable health care is truly a right for all and not a privilege reserved for some.

Overall, it’s important to note that health affects us not just as individuals, but as an entire society. Having an opportunity to a healthy life, without fear of repercussions, is something all children, regardless of immigrant status, deserve.