Methods: We used 3-level random intercept models using logit link function to address violation of independent observations within states with similar adaptation of PRWORA and within a racial/ethnic group sharing similar health beliefs/culture, adopting MCMC method in MLwiN 2.20, which allows Bayesian models to be fitted. MCMC is the best with discrete response models: it has no requirement of normality assumption in making inferences for variance parameters (Browne, 2009).
Results: ‘Healthy Immigrant Effect' due to PRWORA: EIs' health ‘improved' before PRWORA, but ‘deteriorated' after PRWORA 'with passage of time'. Specifically, those with 5-14 years of residence had the poorest health (1.6 times worse compared to U.S.-born and 2.2 times compared to newcomers) and the most disabilities from chronic diseases (1.2 times compared to U.S.-born and 2.5 times compared to newcomers). Their citizenship rates were only 0.45 among the cohort.
Widened Disparities in Health by Nativity: Compared to their U.S.-born counterparts, before PRWORA, most racial/ethnic groups had better health and less disability. Using the self-assessment of health scale, results showed that after PRWORA, except Mexican-American, all groups' health demonstrated great deterioration: Chinese (4.3 times), Filipino (2 times), Mexican-Mexicano (1.5 times), and Black (1.4 times). Reported disabilities also increased greatly: Chinese (2 times), Filipino (4.5 times), API (2.1 times), and Mexican-Mexicano (1.5 times) groups. In sum, they became vulnerable in physical/mental health after PRWORA.
Implications: The findings suggest PRWORA is not working for EIs' physical/mental health. Considering the odds of having poor health for citizens were 0.85 times significantly less than for non-citizens in citizenship-only models, fully embracing EIs into U.S. society by revoking citizenship requirement would be the best policy response. For the vulnerable EIs with 5-14 years of residence, including permanent resident EIs into state-funded welfare provisions can be considered. An additional implication would be that deterioration of minority groups' health may require increasing frontline workers from the immigrants' racial/ethnic groups. They can work better for their elders with greater understanding of EIs' concerns/culture.