The Health Care System and Immigrant Health

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The Health Care System and Immigrant Health
Francesca Gany, M.D., M.S.
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The Center for Immigrant Health NYU School of
Medicine

• Network of over 1000 community members,
  providers, researchers, policymakers engaging in
  creative strategies
• Mission To facilitate the delivery of
  linguistically, culturally, and epidemiologically
  sensitive healthcare services to newcomer
  populations. To eliminate ethnic and racial
  disparities in health care.

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The Center for Immigrant Health NYU School of
Medicine

• We realize our mission through
• Research
• Outreach And Education
• Information Dissemination
• Program Development
• Advocacy

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PARTNERS
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Why Immigrant Health?

• Health Status Deteriorates with Increasing Length
  of Stay
• Specific Health Care Barriers
• The Demographics Demand an Immigrant-specific
  Focus

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Who is an Immigrant?

• An immigrant is a person who is not born in the
  U.S. and who enters the country with the intent
  to remain for an indefinite period of time
• Naturalized Citizen
• Legal Permanent Resident (Green Card)
• Refugee/Asylee
• PRUCOL
• Undocumented Person (most often overstay the
  authorized period of visit)

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U.S. Immigrants

• Over 1 million arrive in the U.S. each year
• Over 28 million Americans were born abroad
• 11 of the U.S. population is foreign-born
• 47 born in Latin America
• 26 born in Asia
• 16 born in Europe

Source U.S. Census Bureau, Population Profile of
the United States 2000 (Internet Release).
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From Where Do Recent Immigrants Come?

• In 2001, five nations of the world constituted
  40 of countries of origin for legal immigration
  to the U.S.
• Mexico (206,426)
• India (70,290)
• China (56,426)
• Philippines (53,154)
• Vietnam (35,531)

Source Annual Report Legal Immigration, Fiscal
Year 2001. U.S. Dept. of Justice Immigration and
Naturalization Services.
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New York City Immigrants

• Over 100,000 documented immigrants arrive each
  year
• NYCs immigrant population grew from 2.1 million
  (1990) to 2.9 million (2000) 38 increase
• 36 of the NYC population (8 million) is foreign
  born

Source U.S. Census Bureau. Population and
Housing Profile  New York City, New York. 2002
American Community Survey Profile.
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From Where Do NYC-based Recent Immigrants Come?

• Immigrants in NYC represent a slightly different
  mix of nationalities
• Dominican Republic
• China
• Jamaica
• Guyana
• Mexico

Source Annual Report Legal Immigration, Fiscal
Year 2001. U.S. Dept. of Justice Immigration and
Naturalization Services.
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How Has This Changed?

• The has changed from 10 years ago, when the top
  countries of origin were
• Dominican Republic
• China
• Jamaica
• Italy
• Soviet Union

Source Annual Report Legal Immigration, Fiscal
Year 2001. U.S. Dept. of Justice Immigration and
Naturalization Services.
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The New York City Picture A Look At the Boroughs

• Queens more than 1,000,000 (707,153)
• Brooklyn 931,800 (672,569)
• Manhattan 452,400 (383,866)
• Bronx 385,800 (274,793)
• Staten Island 72,700 (44,550)
• ( ) population in 1990

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The Health Care System and Health Disparities

• Data Gaps
• Structure of care
• Financing/legal
• Accommodation of cultural and linguistic
  diversity
• Racism

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Data Gaps

• Large Datasets Data not collected by meaningful
  categories
• Lack of disaggregated data, e.g. category Asian
  American

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Data Suggested Categories

• Country-of-Origin New in the Census
• Number of Years in the United States
• Dominant Language
• English Ability
• Parents Ethnicity
• Acculturation Index

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Flow of Care/Structure of Care
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Flow of Care/Structure of Care

• Haphazard, Varies by Locality
• Multiple potential sources of care, no roadmap,
  no orientation
• Out-patient community-based provider, faculty
  practices, managed care groups or staff model
  facilities, neighborhood family health center,
  municipal and voluntary hospital clinic systems,
  ER
• In-patient voluntary system, for-profit,
  municipal
• Pharmacy system not centralized and costly

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Health Screening

• Not mandatory for adults except for documented
  immigrants, refugee assessments done abroad
• No mandatory follow-up once the immigrant arrives
  here
• Children have requirements for school

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Facilities Often Not Receptive

• Hours of Operation
• Location
• Staff Attitudes
• Multiple Points to Navigate
• The Language Barrier Spoken and Written
• Racism

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Windows of Opportunity
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Financial/Legal
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Immigrant Eligibility for Government Health Care
Benefits

• Medicaid and Child Health Plus (A)
• Family Health Plus
• Child Health Plus (B)
• Prenatal Care Assistance Program (PCAP)
• Emergency Medicaid
• Public Hospitals and Community Based Clinics
• Medicare
• Additional Safety Net Services/Block Grants

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Public Charge Issue and Clarification

• Immigration law term
• People who must depend on public benefits
  for income
• Can affect immigrants entry, status, adjustment,
  and may even lead to deportation.
• Justice Department Clarification 1999
• Medicaid (except long-term care) and CHIP not
  subject to possible repayment
• Utilization will not lead to public charge
  determination

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Immigration Concerns and Priorities

• Confidentiality
• Deportation
• Adjustment of Status
• Family Member Sponsorship

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Sponsorship

• Sponsor Deeming
• Deem sponsors resources accessible to the
  immigrant applying for Medicaid
• Sponsor Liability
• State can require sponsor to repay the
  money spent when the immigrant used Medicaid
• To date, New York has not put either into
  practice.

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Language Access
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United States Census

• 1990 Census
• 31 million spoke a language other than English
• 14 million considered limited English proficient
  
• 2000 Census
• 47 million speak a language other than English
• 21 million considered limited English proficient

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LEP Change by State

Source The Access Project National Health Law
Program
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Languages Spoken in NYC

• 24 total NYC population cannot speak English
  very well
• 12 total NYC population speaks English not
  well or not at all
• Top 6 languages spoken at home (NYC overall)
• Spanish (1,832,402)
• Chinese (323,517)
• Russian (194,696)
• Italian (139,698)
• French (105,994)
• Haitian Creole (89,085)

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Language Barriers Impact on Health Care

• Less likely to receive care
• Less likely to understand care
• Increased risk of medical errors
• Reduced quality of care
• Increased risk of unethical care
• Less satisfied with care

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Legislative and Compliance Issues

• Title VI of the Office of Civil Rights Act of
  1964
• Hill Burton Act
• Health Care Financing and Administration
• Joint Committee on Accreditation and Health Care
  Organizations
• Executive Order No. 13166 (Improving Access to
  Services for Persons with Limited English
  Proficiency)
• New Statute in California

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Who Usually Interprets?
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Training of Interpreters is Key
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False Fluency

• .or limited Spanish proficient

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Potential Systemic Solution

• RSMI

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Solutions

• Universal Access
• Community-based Partnerships with Government,
  Academia, and Provider Systems
• Joining Forces to Develop and Disseminate
  Creative Solutions

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For More Information

• www.med.nyu.edu/cih
• Ph [phone]