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Barriers to Health

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Amid deportation threats, exclusionary policies and inflammatory rhetoric, an FSPH study examines how immigrants’ lived experiences affect their access to care.

“One important issue that this study can address is whether experiences with exclusionary policies lead immigrants to avoid public services, which would include seeking medical care in a timely way.”
— Steven P. Wallace

MORE THAN 800,000 undocumented young people brought to the United States as children, along with 300,000-plus foreign-born individuals who have lived and worked here for upward of two decades, face an uncertain future as the Deferred Action for Childhood Arrivals (DACA) and Temporary Protected Status (TPS) programs hang in the balance. The national discourse includes references to “caravans” of migrants headed toward the border, depictions of undocumented immigrants as killers, and appeals for a wall along the Mexican  border. As the rhetoric is ratcheted up, millions of immigrants live with the constant fear that they or a loved one could be deported under an immigration enforcement infrastructure that has grown over the last decade.

These and other developments contribute to a social context with wide-ranging public health implications for all immigrants and their family members — and, by extension, for the overall well-being of the communities across the nation in which immigrants reside, according to Steven P. Wallace, professor of community health sciences and associate director of FSPH’s UCLA Center for Health Policy Research (CHPR), and Maria-Elena Young (PhD ’18), a research scientist at the center and a Chancellor’s Postdoctoral Fellow at UC Merced. Starting in September 2017, with funding from the National Institute on Minority Health and Health Disparities, a team led by Wallace embarked on RIGHTS (Research on ImmiGrant HealTh and State policy), a five-year study to better understand how Asian and Latino immigrants’ experiences with policies in California affect their access to health care.

Although the federal government oversees who can legally enter the country, states have considerable discretion in determining immigrants’ rights, protections and eligibility for social and economic resources, notes Young, the study’s project director. Policies relating to Medicaid and food stamps eligibility, employment and labor issues, university tuition and licenses, and immigration enforcement all shape what it means to be an immigrant in a particular state, she explains.

“We know that eligibility or ineligibility for health services is going to have an impact on health, but there is also a growing recognition that the overall environment in which people live, including the level of discrimination they face and their economic and educational opportunities, affects their health,” Young says. “We believe all of these policies contribute to the overall social climate, and that if you are an immigrant living in an environment that is more inclusive, that’s going to affect your sense of belonging, sense of safety, and willingness to reach out to institutions, pursue opportunities and seek health care.”

The RIGHTS study builds on research Wallace, Young and others have collaborated on for several years. As part of her FSPH doctoral dissertation, Young found that states with more inclusive social and policy environments for immigrants had smaller disparities in access to care between citizens and noncitizens than states with less inclusive environments, even when setting aside specific policies related to health care access.

“There is evidence that state policies have an impact on immigrants’ health and access to health services, but we don’t know much about the actual experiences of immigrants under these policies and how those experiences influence their access to care,” Wallace says. “That’s what we are now studying.”

RIGHTS involves a follow-up to CHPR’s California Health Interview Survey (CHIS), the largest state-level population health survey in the country. A total of 1,000 Latino and 1,000 Asian immigrants who answer questions about their health through the CHIS survey are being interviewed in-depth about their experiences in the areas of health care, social services, labor and employment, law enforcement, and education, as well as about their general perceptions of what it’s like to live as an immigrant in California.

Young notes that California has the nation’s most inclusive policy environment for immigrants, but there is wide variation at the county levels. As part of the study, 60 one-on-one interviews are also being conducted with Mexican and Chinese immigrants living in Los Angeles and Orange counties to provide a detailed understanding of the impact of these county-level differences. Los Angeles is one of the state’s most inclusive counties — providing health coverage to anyone regardless of citizenship status, for example; by contrast, Orange County has contracts with U.S. Immigration and Customs Enforcement (ICE) and helps with the deportation of immigrants, in defiance of the state’s sanctuary law. 

“We’re looking at the manifestations of these policies,” Wallace says. “People may not know whether their local police collaborate with ICE, but they do know if someone has been deported, or if they’ve been injured at work and not reported it, or if they worry about driving through certain parts of town. One important issue that this study can address is whether experiences with exclusionary policies lead immigrants to avoid public services, which would  include seeking medical care in a timely way.” 

Nationally, it’s easy to make the connection between certain policies and immigrant health, Wallace says. DACA and TPS, for example, provide work permits, and the ability to be gainfully employed means individuals are more likely to have health insurance, earn livable wages, and have a stable environment, all of which are health promoting. The uncertain future of those policies represents a threat to both the mental and physical health of their recipients, Wallace notes.

“We want to make sure that policymakers have access to information about who is being excluded and what impact that has, as well as how inclusionary policies could make our society healthier.”
— Maria-Elena Young (PhD ’18)

Other connections are less obvious, and would require additional research to validate — including whether reports of fewer domestic violence calls to police in immigrant communities could be related to fears about immigration enforcement, or to what extent concerns about working without legal documents or driving without the ability to get a license affects the ability of undocumented adults to earn a living and provide a stable, health-promoting environment for their families. Similarly, Wallace and Young point out, research can help to inform the ongoing national debate over comprehensive immigration reform by providing data on the potential public health benefits of enacting a path to citizenship for the more than 10 million undocumented immigrants living in the U.S. 

“Immigrants are an important part of the fabric of our communities and our nation,” Young says. “As public health researchers, we want to make sure that policymakers have access to information about who is being excluded and what impact that has, as well as how inclusionary policies could make our society healthier.”