Evaluating 'healthy Immigrant Effect' of Elderly Immigrants Before and After PRWORA: Findings From the Aggregated NHIS Data In the United States

Purpose: Foreign-born populations are healthier than their native-born counterparts, but the advantage fades away with the passage of time (PoT). Studies call this phenomenon ‘healthy immigrant effect' (HIE) and study why immigrants' health status deteriorates with PoT. Identified determinants of immigrants' health include social, structural, and behavioral determinants. Studies also found that cultural differences explain for variability of immigrants' health. However, no empirical evidence using national data identified ‘environmental effects' on ‘elderly' immigrants (EIs) aged 65 or older. An example of such an effect might be related to policies like PRWORA, which requires citizenship to be eligible for federally-funded benefits. Controlling for states, healthcare service utilization, and other covariates effects, we examined whether HIE can be applied equally to EIs before and/or after PRWORA, whether behavioral changes in health occurred with PoT, and how the changes in response to PRWORA were different by culture, with respect to two health measures: self-assessed health and disability due to chronic diseases. To this aim, we pooled NHIS data (1993-1996 and 2002 -2008 for pre-and post-PRWORA).

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.