On average, per capita health care spending is lower for immigrants than it is for native-born Americans. The non-emergency use of emergency rooms ostensibly indicates an incapacity to pay, yet some studies allege disproportionately lower access to unpaid health care by immigrants. For this and other reasons, there have been various disputes about how much immigration is costing the United States public health system. University of Maryland economist and Cato Institute scholar Julian Lincoln Simon concluded in 1995 that while immigrants probably pay more into the health system than they take out, this is not the case for elderly immigrants and refugees, who are more dependent on public services for survival. Immigration itself may impact women's health. A 2017 study found that Latino women suffer higher rates of intimate partner violence (IPV) than native US women. Migration may worsen IPV rates and outcomes. Migration itself may not cause IPV, but it may make it more difficult for women to get help. According to Kim et al., the IPV is usually the result of unequal family structures rather than the process of migration.