Race/Ethnicity and Legal Status: How Does Legal Status Intersect with Race/Ethnicity in Relation to Private Health Insurance Coverage in the United States?

Background/Purpose: Immigrants’ legal status stratifies access to resources and opportunities in the United States. Despite their high labor force participation, 71% of unauthorized immigrants lack private health insurance coverage. To date, however, there are only a few studies examining how legal status intersects with race and ethnicity to shape immigrants’ day-to-day lives. This study examines the association between legal status and private health insurance, and how this association differs by different racial and ethnic groups. We focus on private health insurance for two reasons. First, health insurance improves access to critical preventive care, and it reduces the risk of being diagnosed at later stages of diseases thereby reducing the risk of mortality. Second, private health insurance coverage is a marker of socioeconomic incorporation because it is mainly obtained through employment.

Methods: To achieve our aim, we used the American Community Survey 2016-2017 – a large nationally representative survey of the U.S. population - and a unique method to impute legal status to compare private health insurance coverage between four major racial/ethnic groups – Hispanics and Non-Hispanic (NH) Black, NH Asian, and NH White immigrants aged 18-64 at the time of the survey. We defined legal status using four categories – naturalized citizens, legal permanent residents (LPRs), legal nonimmigrants (LNIs) (e.g., diplomats), and unauthorized immigrants. Private health insurance was defined as a plan provided by employer or union, a plan purchased individually from a private insurance company, TRICARE, or other military health coverage.

Results: The results of multivariate regression analyses showed that, compared to the three authorized immigrant groups, unauthorized immigrants were the least likely to have private health insurance, and this association was observed across racial/ethnic groups. However, the relationship between legal status and private health insurance was not straightforward – LNIs had the highest rates of insurance coverage. Specifically, after accounting for socioeconomic factors, 86% of Asian LNIs had private health insurance, whereas 67% of the naturalized immigrants had coverage. Among Asian and White immigrants, LPRs were more like to have private health insurance than naturalized immigrants. In contrast, LPRs were less likely to have private health insurance than naturalized immigrants among Hispanic and Black immigrants. Notably, Hispanic immigrants were considerably less likely to have private health insurance than Asian and White immigrants regardless of legal status. Particularly, Hispanic unauthorized immigrants had an average predicted probability of private health insurance that was 23% lower than that of Asian unauthorized immigrants. The difference in private health insurance between Hispanic and Black immigrants was also significant. Across all legal statuses, Asian immigrants had the highest rates of coverage.

Conclusion: Findings indicate that both legal status and race/ethnicity stratify immigrants’ access to private health insurance. While providing immigrants a legalization path may reduce the gap in private health insurance between unauthorized and authorized immigrants, policymakers should also aim to decrease the institutional barriers that minoritized groups - particularly Hispanics and Blacks - encounter in obtaining private health insurance. Further implications will be discussed.