Health Insurance Status and Emergency Room Use by Immigrants with Limited English Proficiency in California

Background/Purpose:

Limited English proficiency (LEP) is a significant barrier to health care access (Flores, 2006). LEP is also associated with employment in low-wage jobs that do not provide health insurance (Wang & Holahan, 2003). Emergency room (ER) care is often the only form of healthcare available to the uninsured and underinsured in the U.S. Recent, non-citizen immigrants are especially likely to have LEP and to be uninsured, accounting for more than 20% of all uninsured individuals nationally (Kaiser Commission on Medicaid and the Uninsured,2006). While the argument exists that recent immigrants disproportionately take advantage of ER services at tax-payers' expense, the evidence is mixed on whether this population does in fact unduly use these services (Ku & Matani,2001).

The objective of this study is to assess the relationship between ER use and health insurance status among immigrants with LEP. The major research question is: Is health insurance status associated with visits to the ER among individuals with LEP? Do the uninsured visit the ER more often? Do the privately insured visit the ER the least, assuming they have the most access to quality resources? Do individuals with LEP differ from the general population in the association between their health insurance status and their ER use? This study tests the hypothesis that, among privately insured, publicly insured, and uninsured individuals within the LEP population, the uninsured have the highest odds of ER use, followed by the publicly insured, followed by the privately insured.

Methods:

Multivariate logistic regression models were used to explore these hypotheses in the 2005 California Health Interview Survey (CHIS). The study sample consisted of foreign-born adults age 19-64 with LEP (N=3366) and was further stratified into sub-samples based on citizenship status. Measures included ER visits in the past 12 months, health insurance type, general health condition, and demographic variables. STATA 10 was used to conduct all analyses.

Results:

Insurance type and general health condition were consistently associated with visits to the ER by all three LEP subpopulations studied: foreign-born adults with LEP, naturalized citizens, and non-citizens with LEP. For all three groups, the uninsured had the lowest odds of ER use and those with public insurance had the greatest odds of ER use (e.g., ORnon-citizen=1.99, p<.0005), when uninsured was the reference group . In the general population, public insurance was also associated with the highest odds of ER use (ORGeneralPop=1.47, p<.0005.), when uninsured was the reference group. But the trend differed in the general population with the privately insured having the lowest odds of ER use (e.g., ORGeneralPop=.879, p<.0005), when uninsured was the reference group.

Conclusions/Implications:

These findings challenge the popular notion that uninsured, recent immigrants disproportionately use ER services and demonstrate that those with LEP differ from the general population in the association between their health insurance status and ER use. Such research has implications for health policy discussions at federal, state,and local levels, particularly in this period of rapid growth of immigrant populations nationwide as well as of vigorous debate about the scope of healthcare reform.