immigrant health care in the united states immigrant health care in the united states immigrant health care in the united states refers to the collective systems in the united states that deliver health care services to immigrants. the term "immigrant" is often used to encompass non-citizens of varying status; this includes permanent legal residents, refugees, and undocumented residents. doctors inspecting immigrants for trachoma at ellis island, 1910 immigrants at ellis island undergoing mandatory health inspections, 19th century immigrant health care is considered distinct from citizen health care, due to intersecting socioeconomic factors and health policies associated with immigration status. disparities in health care usage, coverage, and quality are also observed, not only between immigrants and citizens but also among immigrant groups as well. existing studies have revealed strong correlation of these disparities with a combination of structural and social factors, including lack of insurance, high costs of care, restrictions associated with undocumented status, perceptions of discrimination, and language barriers. intersections of health and immigration policies also create distinctive outcomes for immigrants, such as medical deportations and delivery of medical services in immigration detention centers. policy efforts at reforming the health care system in regards to treatment of immigrants have varied in the past decade. the subject of health care benefits for immigrants has become increasingly popular in political discourse. overview according to the united states department of homeland security, the influx of immigrants into the states has been 1.7 million in 2014, indicating a constant flow of immigrants. furthermore, the united states census bureau projects that this number will continue to increase in the next decade. in addition to its impact on the country's demographics and labor market, this rise in the immigrant population has had a disparate impact on the united states' health care system and its surrounding dialogue. accessibility accessibility of health care services is contingent on factors such as insurance coverage, socioeconomic status, language proficiency, and familiarity with the united states health care system. overall, analyses indicate that after factors such as health status, income, and race and ethnicity are controlled for, citizenship status plays a significant role in determining one's medical care access. since the enactment of the personal responsibility and work opportunity act (prwora) in 1996, the gap in health coverage between immigrants and citizens has grown considerably. immigrants and their children are less likely to be insured, and the lack of insurance consequently reduces their ability to receive care. naturalized citizens, on the other hand, generally receive the same level of health care access as u.s.-born citizens, implying that health care usage becomes more available with acculturation. healthcare providers the health care system in the united states is made up of both public and private insurers, with the private sphere generally dominating in providing coverage. despite this, the federal government remains important given its role in determining public health benefits—for instance, medicaid, the united states health program for families and individuals of low income. following the enactment of prwora in 1996, existing gaps in health care coverage between immigrants and citizens have increased significantly. prwora, in particular, created stricter requirements for immigrants' eligibility for medicaid and similar federal insurance programs. this legislative move largely shifted responsibility for immigrant health care from the federal government to the state and local levels; as such, its impact varies across states. generally, the provisions of prwora prevent immigrants from accessing federal benefits like the state children's health insurance program (schip) until after they have held lawful permanent residency for five years (except in cases of emergency). however, several states have responded by fully funding medicaid-covered services, thus expanding eligibility; among these include states of illinois, new york, the district of columbia, and some counties in california. these services differ accordingly, with some providing the same coverage as medicaid or schip, while others limit coverage to specific categories of immigrants. conversely, other states like arizona, colorado, georgia, and virginia, have implemented laws that further restrict noncitizens' access to health care. legislation of similar nature include the deficit reduction act of 2005, which requires proof of identity and u.s. citizenship from all those applying for/renewing medicaid coverage. in contrast to prwora, the emergency medical treatment and active labor act (emtala) of 1985 provides emergency medical care to all, without any requirements of proof of citizenship or residency. in some areas like washington d.c., uninsured immigrants receive outpatient care from public clinics and community health centers. however, the services offered by this type of health care tends to be uneven; for example, specialty services like pap smears may be offered but not blood pressure tests or follow-up treatments. several municipalities in the united states also offer health care coverage for undocumented immigrants, including los angeles county's my health la program. immigrant usage of complementary and alternative medicine (cam) is also comparatively lower than usage by u.s.-born citizens. a study by bilikisu elewonibi and rhonda belue found that overall cam usage is more likely with health insurance coverage, the latter of which tends to be less common among immigrants. patient protection and affordable care act president barack obama signing the affordable care act, 2010 on march 23, 2010, the patient protection and affordable care act (ppaca) was signed into law by president barack obama. this legislation, joined with the health care and education reconciliation act of 2010, seeks to expand coverage and improve access to the health care system while simultaneously managing its costs. among ppaca's provisions are: the requirement that all u.s. citizens and legal residents possess health insurance; the creation of refundable tax credits for households between 100% and 400% of the federal poverty line; the expansion of medicaid eligibility; the provision of free preventative services; the extension of dependent coverage to age 26; new funding to support community health centers; and more. ppaca's creation of subsidies to make insurance more affordable notably benefits legal residents. in contrast, undocumented immigrants are denied these subsidies and further prohibited from participating in federal or state health insurance exchanges, though their lawfully present children will be eligible. views on the act's contributions to the immigrant population vary. some argue that the reform has immense benefits by addressing coverage gaps and extending more benefits to naturalized citizens. others argue that substantial disparities still exist, with an estimated 3.7 million adults remaining uninsured due to their undocumented status. furthermore, because the act does not address the five-year waiting period placed by prwora, more recent low-income legal immigrants may not seek insurance. quality of care studies on immigrant health care more commonly focus on accessibility, compared to quality. collected data indicates lower levels of heart disease, arthritis, depression, hypertension, asthma, and cancer among immigrants than u.s.-born citizens. speculation behind this phenomenon looks towards the fact that the immigrant population is generally younger than the native-born population as a whole; others believe that these medical conditions simply have not yet been detected given immigrants' lower rates of health coverage. a literature review by kathryn derose, jose escarce, and nicole lurie indicates that immigrant health outcomes appear to worsen as levels of acculturation increase. this may be attributable to a combination of personal behavioral changes and systemic factors, the latter of which includes disparate deliveries of medical care and public health services such as immunizations. uninsured immigrants typically seek outpatient care from public clinics or community health centers. such services tend to perform more poorly in rural areas. research also demonstrates that immigration status is strongly correlated with the perception of being targets of discrimination by health care providers. foreign-born asians and latinos reported higher frequencies of discriminatory experiences compared to their us-born counterparts. undocumented latino immigrants also reported more negative experiences overall. undocumented patients are less likely receive regular, scheduling for life-saving treatments such as dialysis, despite the higher efficacy of scheduled treatments compared to emergency-only. overall, immigrants report more displeasure with their health care experiences than us-born patients do. costs of health care compared to accessibility and quality, there is significantly less research on the costs of immigrant health care in the united states. in general, immigrants have less interaction with the health care system, though incidences in which they do tend more likely to be through emergency departments. on average, immigrants report lower usages of healthcare services. as such, their per capita spending on health care is lower than that of the us-born population. in their research, dana goldman, james smith, and neeraj sood find that health care costs are largely influenced by health insurance coverage. in the year 2000, immigrants' healthcare costs comprised 8.5% of total expenditures on medical care in the united states, while undocumented immigrants' costs were estimated to be approximately 1.5%. lower costs and degrees of medical care usage may be attributable to existing barriers to care, better health outcomes as described by the "healthy immigrant effect," and reluctance to report health problems. demographics children studies indicate that, even if born in the united states, children of non-citizens tend to have poorer health than children of citizens. not only are they more likely to be uninsured, but they also have less access to both medical and dental care. children of immigrants are also less likely to have received proper immunizations than their u.s.-born peers. a 2001 study by sylvia guendelman indicates that foreign-born children are less likely than american-born children to have consistent access to a reliable source of health care. additional findings show that foreign-born children make less ambulatory and emergency visits to hospitals; however, they have considerably higher costs on average when they do, suggesting that immigrant children are sicker or more severely affected during emergencies. this inference is drawn from their lower rates of outpatient and office-based visits. another study done in los angeles county in 2000 found that how children with undocumented parents encountered greater obstacles when trying to access and utilize health care resources. distribution of new immigrants to the united states from 2013 to 2017, by country of origin hispanics and latinos though no precise data on the undocumented immigrant population is available, estimates in 2009 suggest that 70% are from either mexico or central america. a study conducted by pew hispanic center in 2007 indicated that factors that determined quality of care included years of residency in the united states, income level, education status, health insurance coverage, and health literacy. among many immigrant groups, latino communities tend to undergo challenges in healthcare settings and receive lower quality of care than other ethnic groups. data indicates that, in 2002, latinos had an uninsured rate of 33% compared to the national average of 15%. compared to citizens with similar wages, hours, or occupations, hispanic non-citizens were half to two-thirds less likely to be offered health coverage in the workplace. further studies show that regardless of immigration status, non-white hispanics have less access to health care services than white citizens overall. findings indicate that a large body of hispanic and latino americans have similar or better outcomes than the average population—a phenomenon that has been labeled the hispanic paradox. further research indicates that this paradox exists only on some health measures; for example, hispanic immigrants are healthier in terms of blood pressure and heart disease than non-immigrant non-hispanic whites, but are more likely to be overweight or obese and have diabetes. asians health insurance coverage rates vary among asian immigrant subgroups; some asian subgroups match those european immigrants but others, like vietnamese and korean immigrants, had uninsured rates of over 30%. additional research indicates that, compared to children of other ethnic groups, asian children receive the poorest quality of primary care. despite the tendency for less health care access than non-hispanic white citizens, data reviews find that asian ethnicities and immigrant status are correlated with better health and higher school attendance among children. however, this observation of "better health" may potentially be attributed to less diagnoses as a result of less health care utilization. others also suggest that the higher rates of school attendance among asian children may result from cultural values that prioritize education. asian immigrants may practice alternative medicine after migration. for example, vietnamese, chinese, and indonesian immigrants use healing techniques such as gua sha, also known as coin rubbing, and fire cupping. culture assimilation and english literacy have been observed to be major determinants in frequency of health care usage. a study