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Health and health care for legalized aliens
Evaluation and Program Planning, Vol. 14, pp. 251-262, 1991 Printed in the USA. Ah rights reserved.
0149-7189/91 $3.00 + .oo Copyright 0 1991 Pergamon Press plc
HEALTH AND HEALTH CARE FOR LEGALIZED ALIENS
DONALD E. GELFAND University of Maryland at Baltimore
ABSTRACT Under provisions of the 1986 immigration Reform and Control Act, almost two miilion iilegal aliens appliedfor legalization in the United States between May I, 1987 and May I, 1988. Over 1300 applicants for legalization were interviewed in Maryland during 1988. A reiativeiy young group, respondents rated their hearth as posiiive and their responses to a symptom checklist supported this assessment. Over half of the respondents had no health insurance, andpresence or absence of health insurance was strongly related to occupational classification. The survey indicated a need for primary prevention programs, attention to cuItura( norms of the applicants, and the need of applicants to obtain jobs that offer health insurance.
INTRODUCTION migration system in 1965 eliminated the so-called “quota system,” which provided more “slots” for individuals from European countries than other parts of the world. The new system, however, allotted 20,~ slots to each country and emphasized the principle of reunification of families. The 20,000 slots hardly met the demand for immigration from countries in Central and South America, where economic deterioration and political violence have made living conditions intolerable for many. Family reunification also failed to help individuals from these countries, because they had few relatives in the United States. Massive illegal immigration has been the result of these obstacles to immigration, particularly from Central and South America. Although exact numbers are hardly known, the best estimates are that illegal immigrants probably number around 2,000,OOOindividuals (Passel, 1986), but there are also claims that the actual numbers are higher. The legalization of illegal aliens was made possible through provisions of the 1986 Immigration Reform and Control Act (IRCA). The IRCA was an effort both to control immigration by providing more funds to the Immigration and Naturalization Service (INS) and to allow individuals who had been living in the United
Access to quality health care and cost containment are two major issues facing the troubled American health care system. This article examines the health status and potential health care access issues faced by one specific U.S. population group: formerly illegal aliens who have applied for legalization in the United States. There are enormous gaps in our knowledge about illegal aliens. There is little solid data on their health status, prevalence of any important health conditions, attitudes towards health care and services, and other factors that influence their health status. Planning and providing effective health services for formerly illegal aliens also involves important cultural elements because, at present, the majority of these individuals are from “minority” backgrounds. As can be seen from the data in this article, the major ethnic groups represented among the study population includes Hispanics, Africans, and Asians. ~mmig~tion History and Illegals The desire to come to the United States has been a dream in many countries, but American immigration law has not always been oriented to countries where the desire for emigration is the greatest. Reform of the im-
This research was conducted under a contract with the Maryland Office of Refugee Affairs, Community Services Administration, Department of Human Resources. I am grateful to Frank Bien, Director of the Office, who initiated the project and to Ann Bouculat, the Project Officer, for her support and assistance. Lillian M. Lynch was the invaluable Project Assistant. The views expressed are soldy those of the author. Requests for reprints should be sent to Donaid E. Gelfand, School of Social Work, University of Maryland at Baltimore, 525 W. Redwood St., Baltimore, MD 21201.
257
258
DONALD
States illegally for a number of years to change their status. Under IRCA two types of persons could apply to become legal: (a) individuals who had lived illegally in the United States ~o~~jn~ously since before Ianuary 1, 1982; (b) Special Agricuitural Workers who had been in the United States for three years and had worked in agriculture for at least 90 days during each of those years or had worked 90 days in agriculture in the period between May 1, 1985 and May I, 1986. There were only three grounds for refusing an application: conviction of the person for committing a felony; having been a
E. GELFAND
“public charge” (basically, accepting Aid to Families with Dependent Children); or testing positive for the HIV virus. Approval of the application provided a temporary work permit. For more permanent legal status, the individual had to be able to show satisfactory progress in an English language course or pass an INS designed test within 18 months of approval of the initial application. The proportion of the original applicant pool that will progress through this second stage is, as yet, unclear.
METHODS The data presented here represent information collected as part of a survey of applicants for legalization in Maryland, the only survey undertaken in the United States during the application period. All individuals who utilized community organizations to process their applications were asked to participate in the survey. Iml~igration attorneys were also contacted and asked to solicit the consent of their clients to be interviewed. Finally, interviewers were stationed at the state legalization office. As individuals completed their applications for legalization, their participation in the survey was solicited by the interviewers. The interview was translated into Spanish, Creole, and Mandarin, and backtranslated for accuracy. interviews were administered by individuals fluent in the relevant language. A total of 1326 interviews were collected. This figure represented over 17% of the 7,777 individuals who had applied for legalization in Maryland by the end of the legalization period for non-agricultural workers on May 4, 1988. Sixty-one percent of the interviews were obtained at community agencies processing applications, and 38% at the state legalization office. Of the 38% of the respondents interviewed at the legalization office, approximately haIf were represented by private attorneys. The sample does not represent a random sample of ii-
legal aliens resident in Maryland, but a sample of individuals who applied for legalization in the State. Given the low refusal rate (17%) and the large number of interviews obtained, the data are felt to reflect accurately the backgrounds and characteristics of the legalization applicants in Maryland. Because of the small number of Mexicans, the Maryland data wit1 not be fully comparable with data of states such as California or Texas where Mexicans were the dominant applicant group. The Maryland data do, however, have strong applicability to many other States. Interviews were coltected from individuals from 75 different countries. As Table 1 indicates, the national origins of those interviewed by the University of Maryland at Baltimore (UMAB) interviewers were representative of the national origins of individuals who applied for legalization in the state. For purposes of analysis, the respondents were classified into six groups: Mexicans, and Central and South Americans (MCSA) (n = 692); Africans (n = 3 16); Caribbeans (n = 147); Middle Easterners (n = 67); Asians (n = 6); and Europeans (n = 25). A summary of the demographic characteristics of the respondents by group is shown in Table 2.
RESULTS Unfortunately, although all applicants were required to undergo a physical examination as part of the legalization application, these data were not processed by the INS so that they could be analyzed on an aggregate basis. To provide information on health status, a subjective evaluation by respondents of their own and their family’s health was obtained. Almost all the respondents evaluated their general health as excellent or good (Table 3). This favorable health estimate also held true for their spouses and children. Males perceived their health as excellent more frequently than females. Less than one percent of all respondents viewed their health as poor. Whatever their current evaluation, the majority of the respondents did not perceive a major change in their
health status from when they first arrived in the U.S. (Table 4). Private doctors provided health care for the majority of the respondents, but there was also some usage of clinics and hospital emergency rooms (Table 5). The small group of Europeans utilized private doctors less frequently than the other groups, and were more frequent patronizers of clinics. Both the Africans and Caribbeans made use of hospital emergency rooms mote frequently than respondents from other regions. The prevalence of specific health conditions was evaluated on the basis of the respondents’ answers to a check list developed by a local county heahh department for health assessments of refugees. Based on their self-reports, serious health problems did not appear to
Health
and Health
Care for Legalized
TABLE 1 COUNTRY OF ORIGIN OF UMAB SURVEY AND INS MARYLAND APPLICANTS
SUMMARY
(top 10) INS MD Applicants (n = 7777)
UMAB Survey (n = 1320) % El Salvador Nigeria Mexico Haiti Iran Guatemala Sierra Leone Liberia Ghana Jamaica l
Percentages
No.
l
30 10 8 5 5 4 4 3 3 2
El Salvador Nigeria Mexico Haiti Iran Sierra Leone Ghana Jamaica Guatemala Ethiopia
(393) (125) (107) (69) (59) (57) (46) (45) (37) (32)
Aliens TABLE 2 OF DEMOGRAPHIC AND SOCIOECONOMIC CHARACTERISTICS OF MARYLAND LEGALIZATION APPLICANTS (/I = 1316)
Age
%+
No.
23
(1789)
Sex Marital status
11
(855)
10 8 6 4 3 3 3 3
(777) (622) (467) (288) (226) (210) (210) (202)
259
Children
Education Income
Median age Age group 25-44 years Mate Female Married Lives with companion Divorced Separated Never married Widowed Median age Families with 3 or more children Living in U.S. Median education Median family income
32 77% 64% 36% 38% 13% 5% 7% 37% 1% 9 30% 63% 1 O-l 2 years $14,000-l 5,999
are rounded off.
TABLE 3 PERCEIVED GENERAL HEALTH STATUS (%)’
Health Status Excellent Good Fair Poor ‘Percentages
Total (n = 1325)
Mexico/Central/ South America (n = 692)
Africa (n = 316)
Caribbean (n = 146)
Middle East (n = 67)
Asia (n = 66)
Europe (n = 25)
59 34 7 -
49 41 9 1
75 23 2 -
68 25 7 1
72 24 2 3
53 41 6 -
68 24 8 -
may not add up to 100% because of rounding
TABLE 4 HEALTH STATUS NOW VS. WHEN FIRST ARRIVED IN U.S. (%)*
PERCEIVED COMPARATIVE
Health Status
Mexico/Central/ South America (n = 684)
Africa (n = 312)
Caribbean (n = 146)
Middle East (n = 67)
Asia (n = 65)
Europe (n = 25)
64 27 10
71 21 9
57 32 12
75 10 15
69 20 11
80 12 8
66 24 10
Same Better Worse ‘Percentages
Total (n=1311)
may not add up to 100% because of rounding
TABLE 5 MEDICAL FACILITIES UTILIZED (%)’
Facility Private doctor Clinic Hospital Emergency l
Percentages
Room
Total (n = 1284)
Mexico/Central/ South America (n = 664)
Africa (n = 307)
Caribbean (n = 146)
Middle East (n = 66)
Asia (n = 65)
Europe (n = 24)
53 22 10
53 26 5
46 19 20
54 21 14
74 9 8
63 12 5
38 33 8
may not add up to 100% because of multiple responses.
260
DONALD
E. GELFAND
TABLE 6 MEDICAL INSURANCE COVERAGE BY REGION (%)’
Total (n = 1309)
Mexico/Central/ South America (n = 681)
Africa (n = 313)
Caribbean (n = 144)
Middle East (n = 67)
(n = 66)
Europe (n = 25)
55
69
43
33
42
35
40
No coverage l
Percentages
may not add up to 100% because of rounding
TABLE 7 MEDICAL INSURANCE COVERAGE BY OCCUPATION (n= 1114)
No coverage *Percentages
Asia
Professional/ Technical
Executive/ Administrative/ Managerial
26
29
(%)*
Sales
Admin supp/ Clerical
Precision/ Repair
Operator/ Fabricator/ Laborer
Farm/ Fishing
Services
42
32
57
63
50
64
may not add up to 100% because of rounding.
be common among the respondents. Asked what health problems were diagnosed by a doctor, only high blood pressure appeared to be a serious health condition. Hypertension was cited as a health problem by 11% of the applicants, and was the only health problem common across all of the regions. The regional breakdown disclosed differences in specific diseases: malaria among the African respondents, arthritis among the Europeans. An examination of the distribution of health conditions by sex indicates that significantly more women had high blood pressure and arthritis than males (ratios of 1.9: 1 and 2: 1, respectively). The existing health conditions among the respondents did not produce any major use of special health aids, except for glasses/contact lenses (29%) and dentures (20%). Beyond the presence or absence of specific health problems, the study revealed that 55% of the respondents had no health insurance (Table 6). This lack of insurance coverage did not vary by sex, but it did relate to the region of origin. Among all of the regional
groups, the MCSA were the group with the highest percentage of individuals without health insurance. Analysis by occupation (Table 7) established that 64% of those in the service industries and 63% of the operators/fabricators/laborers had no health insurance. At the other end of the occupational spectrum, 26% of those employed in professional/technical fields and 29% of executive/administrative/managerial employees lacked health insurance coverage. A cross tabulation indicated differences in lack of health insurance according to age. The highest percentage of individuals without health insurance was from the small (n = 32) number of respondents over the age of 65. Controlling for occupation, however, reduced the significant differences by age, again reinforcing the linkage of occupation to health insurance coverage. The linkage of health insurance to adequate health care was evidenced by the respondents who reported that there were times when they did not receive needed medical treatment (10%) because of insufficient funds.
DISCUSSION Self-reports of health may underestimate health problems because of fears individuals have about admitting to health problems. This would be particularly true among a group of individuals (such as those interviewed) who were afraid of revealing anything that might jeopardize their legalization application. Individuals may also underestimate their health problems because of a lack of knowledge of existing conditions, particularly if the health care they have received in the past has been limited. If the INS releases the health examination data, a full evaluation of the health status of
the two million legalization applicants across the country will be obtainable. At this point, however, there are a number of reasons to believe that the self-reports of the sample were accurate. In the vast majority of cases, illegal aliens come to the United States to obtain employment. It is doubtful that a significant number of seriously ill individuals would seek to emigrate, particularly given the arduous conditions under which many of these individuals have lived in the United States. The young median age of the population also argues for a positive health status.
Health
and Health
Care for Legalized Aliens
Despite all of these positive indicators, the data do indicate the need for a number of health services. Immediately evident are those that stem from the large number of applicant women in the childbearing ages. These services include prenatal care, and family and genetic counseling. Screening, early detection, and control programs aimed at the prevention of hypertension or strokes would also benefit the legalized aliens. The prevalence of denture use among the respondents (29%) was markedly higher than among the general American population (less than 10%) (Findings, 1977). The causes of the high use of dentures include the possibility of limited dental care, poor dental hygiene, and poor diets in countries such as El Salvador. Nutrition and oral health education programs are both potentially important in the battle against increased dental problems among this new immigrant population. Beyond primary and secondary prevention programs, the applicants in the survey face the major problem of affording the health care treatment now available in the United States. This problem existed when the applicants were classified as “illegal” or “undocumented” workers and were forced to rely on clinics, especially those run by the Catholic church. Legalization implies opportunities to “come out of the shadows” and live a better life in the U.S. in all regards. The cost of health care threatens this possibility. In 1988, there was public concern that 37 million Americans did not have health insurance. This figure equals 17% of the population, a substantially lower figure than the 55% of the study sample. It is also noteworthy that the lack of health insurance coverage was highest among the individuals with the lowest income levels. Depending on family size, some of these individuals may have qualified for assistance under the categorically needy provisions of Medicaid. As their health profile indicates, few of the respondents would qualify under Medicaid’s medically needy provisions. Because the IRCA made legalization applicants ineligible for federally funded Medicaid for five years, the states will need to help uninsured legalization applicants meet their health care needs. It is clear that for many of the legalized aliens, the ability to obtain health insurance is job related. This link to employment is supported by a California study of SAWS which indicated that only 29% had health insurance (Kissam & Intili, 1988). Among self-employed professionals, health insurance is linked to the ability to obtain either affordable individual rates or membership in professional organizations that provide health insurance. If health insurance is linked to employment, then one obvious strategy is to assist legalizing aliens in obtaining better, more stable jobs where health insurance is an available benefit. The indices on education and language proficiency indicate that both more advanced ed-
261
ucation and more English language skills will be needed before many of the respondents can obtain better jobs. Alternatively, a plan requiring all employers to provide health benefits could make an impact on this problem. It is of course possible that many construction workers not offered health insurance by their employers will prefer to have higher salaries rather than payroll deductions for health insurance. This risk-taking, however, has negative implications for both the worker and the health care system. At this point, however, it cannot be assumed that the only obstacle to adequate health care among legalized aliens is the lack of insurance coverage. The data indicate a substantial population of new Americans from ethnic backgrounds not previously encountered in any significant numbers by many programs and service providers. Besides the extensive immigration from Hispanic countries, there are also important new groups of individuals from a variety of Asian and African countries. All of these individuals come from distinct cultures with norms about relationships, living patterns, and health care. For legalized aliens from some countries, the use of formal health care services may not be part of the culture (Harwood, 1981; Tung, 1980). Health care providers need to take these cultural norms into account. For example, nutrition education programs that do not take into account ethnic dietary preferences among Salvadorans, Nicaraguans, and Iranians will not be effective. Many formerly illegal aliens may also have only limited knowledge about formal health care options, particularly if the literature available on these options is available only in English. Health education efforts with many of these populations must thus include some elements not usually considered part of standard procedures. These include the provision of information to families about the American health care system, including its complex financing, and the different types of health care plans available. Many of the Central and South Americans had only limited educational backgrounds. Helping them understand these complex health care coverages may require translation of important materials into Spanish and the use of a format that is easily understood. Education about the American health care system, however, assumes that many formerly illegal aliens will be able to obtain health insurance. Unless adequate health care coverage for legalized aliens becomes available, their major health care provider will probably be local health departments or overburdened hospital emergency rooms and clinics. Local health departments may also be forced into an even greater role of providing health education, screening, and treatment efforts for many legalized aliens. Whether local governments are able to take on this major responsibility is open to question.
262
DONALD
Fortunately (unless the Immigration and Naturalization Service data from the physical examinations prove otherwise), the health status of the relatively youthful legalization applicants was extremely positive. As these new American citizens age, a lack of adequate health
E. GELFAND
care may result in a high prevalence rate of chronic conditions. At that point in time, the health care costs may be much higher than the current costs of a concerted effort to increase the access of these individuals to regular, quality health care.
REFERENCES Findings from the Ad Hoc Committee for the Delivery of Quality Prosthetic Care for the Financially Disadvantaged. (1977). Journal of fhe Americun Dental Associaiion, 77, 1024- 1038. HARWOOD, bridge, MA.:
A. (Ed.). (1981). Ethnicily Harvard University Press.
KISSAM,
cure. Cam-
E., & INTILI, J. (1888). Preliminary results, California HuCorporation survey of legalization applicants. Rosa. CA: Author.
nmn Development
Santa
and medical
PASSEL, 181-191.
J. (1986). Undocumented
TUNG, T. (1980). Indochinesepatients. South East Asians.
immigration.
Falls Church,
The Annals,
487,
VA.: Action for
0149-7189/91 $3.00 + .oo Copyright 0 1991 Pergamon Press plc
HEALTH AND HEALTH CARE FOR LEGALIZED ALIENS
DONALD E. GELFAND University of Maryland at Baltimore
ABSTRACT Under provisions of the 1986 immigration Reform and Control Act, almost two miilion iilegal aliens appliedfor legalization in the United States between May I, 1987 and May I, 1988. Over 1300 applicants for legalization were interviewed in Maryland during 1988. A reiativeiy young group, respondents rated their hearth as posiiive and their responses to a symptom checklist supported this assessment. Over half of the respondents had no health insurance, andpresence or absence of health insurance was strongly related to occupational classification. The survey indicated a need for primary prevention programs, attention to cuItura( norms of the applicants, and the need of applicants to obtain jobs that offer health insurance.
INTRODUCTION migration system in 1965 eliminated the so-called “quota system,” which provided more “slots” for individuals from European countries than other parts of the world. The new system, however, allotted 20,~ slots to each country and emphasized the principle of reunification of families. The 20,000 slots hardly met the demand for immigration from countries in Central and South America, where economic deterioration and political violence have made living conditions intolerable for many. Family reunification also failed to help individuals from these countries, because they had few relatives in the United States. Massive illegal immigration has been the result of these obstacles to immigration, particularly from Central and South America. Although exact numbers are hardly known, the best estimates are that illegal immigrants probably number around 2,000,OOOindividuals (Passel, 1986), but there are also claims that the actual numbers are higher. The legalization of illegal aliens was made possible through provisions of the 1986 Immigration Reform and Control Act (IRCA). The IRCA was an effort both to control immigration by providing more funds to the Immigration and Naturalization Service (INS) and to allow individuals who had been living in the United
Access to quality health care and cost containment are two major issues facing the troubled American health care system. This article examines the health status and potential health care access issues faced by one specific U.S. population group: formerly illegal aliens who have applied for legalization in the United States. There are enormous gaps in our knowledge about illegal aliens. There is little solid data on their health status, prevalence of any important health conditions, attitudes towards health care and services, and other factors that influence their health status. Planning and providing effective health services for formerly illegal aliens also involves important cultural elements because, at present, the majority of these individuals are from “minority” backgrounds. As can be seen from the data in this article, the major ethnic groups represented among the study population includes Hispanics, Africans, and Asians. ~mmig~tion History and Illegals The desire to come to the United States has been a dream in many countries, but American immigration law has not always been oriented to countries where the desire for emigration is the greatest. Reform of the im-
This research was conducted under a contract with the Maryland Office of Refugee Affairs, Community Services Administration, Department of Human Resources. I am grateful to Frank Bien, Director of the Office, who initiated the project and to Ann Bouculat, the Project Officer, for her support and assistance. Lillian M. Lynch was the invaluable Project Assistant. The views expressed are soldy those of the author. Requests for reprints should be sent to Donaid E. Gelfand, School of Social Work, University of Maryland at Baltimore, 525 W. Redwood St., Baltimore, MD 21201.
257
258
DONALD
States illegally for a number of years to change their status. Under IRCA two types of persons could apply to become legal: (a) individuals who had lived illegally in the United States ~o~~jn~ously since before Ianuary 1, 1982; (b) Special Agricuitural Workers who had been in the United States for three years and had worked in agriculture for at least 90 days during each of those years or had worked 90 days in agriculture in the period between May 1, 1985 and May I, 1986. There were only three grounds for refusing an application: conviction of the person for committing a felony; having been a
E. GELFAND
“public charge” (basically, accepting Aid to Families with Dependent Children); or testing positive for the HIV virus. Approval of the application provided a temporary work permit. For more permanent legal status, the individual had to be able to show satisfactory progress in an English language course or pass an INS designed test within 18 months of approval of the initial application. The proportion of the original applicant pool that will progress through this second stage is, as yet, unclear.
METHODS The data presented here represent information collected as part of a survey of applicants for legalization in Maryland, the only survey undertaken in the United States during the application period. All individuals who utilized community organizations to process their applications were asked to participate in the survey. Iml~igration attorneys were also contacted and asked to solicit the consent of their clients to be interviewed. Finally, interviewers were stationed at the state legalization office. As individuals completed their applications for legalization, their participation in the survey was solicited by the interviewers. The interview was translated into Spanish, Creole, and Mandarin, and backtranslated for accuracy. interviews were administered by individuals fluent in the relevant language. A total of 1326 interviews were collected. This figure represented over 17% of the 7,777 individuals who had applied for legalization in Maryland by the end of the legalization period for non-agricultural workers on May 4, 1988. Sixty-one percent of the interviews were obtained at community agencies processing applications, and 38% at the state legalization office. Of the 38% of the respondents interviewed at the legalization office, approximately haIf were represented by private attorneys. The sample does not represent a random sample of ii-
legal aliens resident in Maryland, but a sample of individuals who applied for legalization in the State. Given the low refusal rate (17%) and the large number of interviews obtained, the data are felt to reflect accurately the backgrounds and characteristics of the legalization applicants in Maryland. Because of the small number of Mexicans, the Maryland data wit1 not be fully comparable with data of states such as California or Texas where Mexicans were the dominant applicant group. The Maryland data do, however, have strong applicability to many other States. Interviews were coltected from individuals from 75 different countries. As Table 1 indicates, the national origins of those interviewed by the University of Maryland at Baltimore (UMAB) interviewers were representative of the national origins of individuals who applied for legalization in the state. For purposes of analysis, the respondents were classified into six groups: Mexicans, and Central and South Americans (MCSA) (n = 692); Africans (n = 3 16); Caribbeans (n = 147); Middle Easterners (n = 67); Asians (n = 6); and Europeans (n = 25). A summary of the demographic characteristics of the respondents by group is shown in Table 2.
RESULTS Unfortunately, although all applicants were required to undergo a physical examination as part of the legalization application, these data were not processed by the INS so that they could be analyzed on an aggregate basis. To provide information on health status, a subjective evaluation by respondents of their own and their family’s health was obtained. Almost all the respondents evaluated their general health as excellent or good (Table 3). This favorable health estimate also held true for their spouses and children. Males perceived their health as excellent more frequently than females. Less than one percent of all respondents viewed their health as poor. Whatever their current evaluation, the majority of the respondents did not perceive a major change in their
health status from when they first arrived in the U.S. (Table 4). Private doctors provided health care for the majority of the respondents, but there was also some usage of clinics and hospital emergency rooms (Table 5). The small group of Europeans utilized private doctors less frequently than the other groups, and were more frequent patronizers of clinics. Both the Africans and Caribbeans made use of hospital emergency rooms mote frequently than respondents from other regions. The prevalence of specific health conditions was evaluated on the basis of the respondents’ answers to a check list developed by a local county heahh department for health assessments of refugees. Based on their self-reports, serious health problems did not appear to
Health
and Health
Care for Legalized
TABLE 1 COUNTRY OF ORIGIN OF UMAB SURVEY AND INS MARYLAND APPLICANTS
SUMMARY
(top 10) INS MD Applicants (n = 7777)
UMAB Survey (n = 1320) % El Salvador Nigeria Mexico Haiti Iran Guatemala Sierra Leone Liberia Ghana Jamaica l
Percentages
No.
l
30 10 8 5 5 4 4 3 3 2
El Salvador Nigeria Mexico Haiti Iran Sierra Leone Ghana Jamaica Guatemala Ethiopia
(393) (125) (107) (69) (59) (57) (46) (45) (37) (32)
Aliens TABLE 2 OF DEMOGRAPHIC AND SOCIOECONOMIC CHARACTERISTICS OF MARYLAND LEGALIZATION APPLICANTS (/I = 1316)
Age
%+
No.
23
(1789)
Sex Marital status
11
(855)
10 8 6 4 3 3 3 3
(777) (622) (467) (288) (226) (210) (210) (202)
259
Children
Education Income
Median age Age group 25-44 years Mate Female Married Lives with companion Divorced Separated Never married Widowed Median age Families with 3 or more children Living in U.S. Median education Median family income
32 77% 64% 36% 38% 13% 5% 7% 37% 1% 9 30% 63% 1 O-l 2 years $14,000-l 5,999
are rounded off.
TABLE 3 PERCEIVED GENERAL HEALTH STATUS (%)’
Health Status Excellent Good Fair Poor ‘Percentages
Total (n = 1325)
Mexico/Central/ South America (n = 692)
Africa (n = 316)
Caribbean (n = 146)
Middle East (n = 67)
Asia (n = 66)
Europe (n = 25)
59 34 7 -
49 41 9 1
75 23 2 -
68 25 7 1
72 24 2 3
53 41 6 -
68 24 8 -
may not add up to 100% because of rounding
TABLE 4 HEALTH STATUS NOW VS. WHEN FIRST ARRIVED IN U.S. (%)*
PERCEIVED COMPARATIVE
Health Status
Mexico/Central/ South America (n = 684)
Africa (n = 312)
Caribbean (n = 146)
Middle East (n = 67)
Asia (n = 65)
Europe (n = 25)
64 27 10
71 21 9
57 32 12
75 10 15
69 20 11
80 12 8
66 24 10
Same Better Worse ‘Percentages
Total (n=1311)
may not add up to 100% because of rounding
TABLE 5 MEDICAL FACILITIES UTILIZED (%)’
Facility Private doctor Clinic Hospital Emergency l
Percentages
Room
Total (n = 1284)
Mexico/Central/ South America (n = 664)
Africa (n = 307)
Caribbean (n = 146)
Middle East (n = 66)
Asia (n = 65)
Europe (n = 24)
53 22 10
53 26 5
46 19 20
54 21 14
74 9 8
63 12 5
38 33 8
may not add up to 100% because of multiple responses.
260
DONALD
E. GELFAND
TABLE 6 MEDICAL INSURANCE COVERAGE BY REGION (%)’
Total (n = 1309)
Mexico/Central/ South America (n = 681)
Africa (n = 313)
Caribbean (n = 144)
Middle East (n = 67)
(n = 66)
Europe (n = 25)
55
69
43
33
42
35
40
No coverage l
Percentages
may not add up to 100% because of rounding
TABLE 7 MEDICAL INSURANCE COVERAGE BY OCCUPATION (n= 1114)
No coverage *Percentages
Asia
Professional/ Technical
Executive/ Administrative/ Managerial
26
29
(%)*
Sales
Admin supp/ Clerical
Precision/ Repair
Operator/ Fabricator/ Laborer
Farm/ Fishing
Services
42
32
57
63
50
64
may not add up to 100% because of rounding.
be common among the respondents. Asked what health problems were diagnosed by a doctor, only high blood pressure appeared to be a serious health condition. Hypertension was cited as a health problem by 11% of the applicants, and was the only health problem common across all of the regions. The regional breakdown disclosed differences in specific diseases: malaria among the African respondents, arthritis among the Europeans. An examination of the distribution of health conditions by sex indicates that significantly more women had high blood pressure and arthritis than males (ratios of 1.9: 1 and 2: 1, respectively). The existing health conditions among the respondents did not produce any major use of special health aids, except for glasses/contact lenses (29%) and dentures (20%). Beyond the presence or absence of specific health problems, the study revealed that 55% of the respondents had no health insurance (Table 6). This lack of insurance coverage did not vary by sex, but it did relate to the region of origin. Among all of the regional
groups, the MCSA were the group with the highest percentage of individuals without health insurance. Analysis by occupation (Table 7) established that 64% of those in the service industries and 63% of the operators/fabricators/laborers had no health insurance. At the other end of the occupational spectrum, 26% of those employed in professional/technical fields and 29% of executive/administrative/managerial employees lacked health insurance coverage. A cross tabulation indicated differences in lack of health insurance according to age. The highest percentage of individuals without health insurance was from the small (n = 32) number of respondents over the age of 65. Controlling for occupation, however, reduced the significant differences by age, again reinforcing the linkage of occupation to health insurance coverage. The linkage of health insurance to adequate health care was evidenced by the respondents who reported that there were times when they did not receive needed medical treatment (10%) because of insufficient funds.
DISCUSSION Self-reports of health may underestimate health problems because of fears individuals have about admitting to health problems. This would be particularly true among a group of individuals (such as those interviewed) who were afraid of revealing anything that might jeopardize their legalization application. Individuals may also underestimate their health problems because of a lack of knowledge of existing conditions, particularly if the health care they have received in the past has been limited. If the INS releases the health examination data, a full evaluation of the health status of
the two million legalization applicants across the country will be obtainable. At this point, however, there are a number of reasons to believe that the self-reports of the sample were accurate. In the vast majority of cases, illegal aliens come to the United States to obtain employment. It is doubtful that a significant number of seriously ill individuals would seek to emigrate, particularly given the arduous conditions under which many of these individuals have lived in the United States. The young median age of the population also argues for a positive health status.
Health
and Health
Care for Legalized Aliens
Despite all of these positive indicators, the data do indicate the need for a number of health services. Immediately evident are those that stem from the large number of applicant women in the childbearing ages. These services include prenatal care, and family and genetic counseling. Screening, early detection, and control programs aimed at the prevention of hypertension or strokes would also benefit the legalized aliens. The prevalence of denture use among the respondents (29%) was markedly higher than among the general American population (less than 10%) (Findings, 1977). The causes of the high use of dentures include the possibility of limited dental care, poor dental hygiene, and poor diets in countries such as El Salvador. Nutrition and oral health education programs are both potentially important in the battle against increased dental problems among this new immigrant population. Beyond primary and secondary prevention programs, the applicants in the survey face the major problem of affording the health care treatment now available in the United States. This problem existed when the applicants were classified as “illegal” or “undocumented” workers and were forced to rely on clinics, especially those run by the Catholic church. Legalization implies opportunities to “come out of the shadows” and live a better life in the U.S. in all regards. The cost of health care threatens this possibility. In 1988, there was public concern that 37 million Americans did not have health insurance. This figure equals 17% of the population, a substantially lower figure than the 55% of the study sample. It is also noteworthy that the lack of health insurance coverage was highest among the individuals with the lowest income levels. Depending on family size, some of these individuals may have qualified for assistance under the categorically needy provisions of Medicaid. As their health profile indicates, few of the respondents would qualify under Medicaid’s medically needy provisions. Because the IRCA made legalization applicants ineligible for federally funded Medicaid for five years, the states will need to help uninsured legalization applicants meet their health care needs. It is clear that for many of the legalized aliens, the ability to obtain health insurance is job related. This link to employment is supported by a California study of SAWS which indicated that only 29% had health insurance (Kissam & Intili, 1988). Among self-employed professionals, health insurance is linked to the ability to obtain either affordable individual rates or membership in professional organizations that provide health insurance. If health insurance is linked to employment, then one obvious strategy is to assist legalizing aliens in obtaining better, more stable jobs where health insurance is an available benefit. The indices on education and language proficiency indicate that both more advanced ed-
261
ucation and more English language skills will be needed before many of the respondents can obtain better jobs. Alternatively, a plan requiring all employers to provide health benefits could make an impact on this problem. It is of course possible that many construction workers not offered health insurance by their employers will prefer to have higher salaries rather than payroll deductions for health insurance. This risk-taking, however, has negative implications for both the worker and the health care system. At this point, however, it cannot be assumed that the only obstacle to adequate health care among legalized aliens is the lack of insurance coverage. The data indicate a substantial population of new Americans from ethnic backgrounds not previously encountered in any significant numbers by many programs and service providers. Besides the extensive immigration from Hispanic countries, there are also important new groups of individuals from a variety of Asian and African countries. All of these individuals come from distinct cultures with norms about relationships, living patterns, and health care. For legalized aliens from some countries, the use of formal health care services may not be part of the culture (Harwood, 1981; Tung, 1980). Health care providers need to take these cultural norms into account. For example, nutrition education programs that do not take into account ethnic dietary preferences among Salvadorans, Nicaraguans, and Iranians will not be effective. Many formerly illegal aliens may also have only limited knowledge about formal health care options, particularly if the literature available on these options is available only in English. Health education efforts with many of these populations must thus include some elements not usually considered part of standard procedures. These include the provision of information to families about the American health care system, including its complex financing, and the different types of health care plans available. Many of the Central and South Americans had only limited educational backgrounds. Helping them understand these complex health care coverages may require translation of important materials into Spanish and the use of a format that is easily understood. Education about the American health care system, however, assumes that many formerly illegal aliens will be able to obtain health insurance. Unless adequate health care coverage for legalized aliens becomes available, their major health care provider will probably be local health departments or overburdened hospital emergency rooms and clinics. Local health departments may also be forced into an even greater role of providing health education, screening, and treatment efforts for many legalized aliens. Whether local governments are able to take on this major responsibility is open to question.
262
DONALD
Fortunately (unless the Immigration and Naturalization Service data from the physical examinations prove otherwise), the health status of the relatively youthful legalization applicants was extremely positive. As these new American citizens age, a lack of adequate health
E. GELFAND
care may result in a high prevalence rate of chronic conditions. At that point in time, the health care costs may be much higher than the current costs of a concerted effort to increase the access of these individuals to regular, quality health care.
REFERENCES Findings from the Ad Hoc Committee for the Delivery of Quality Prosthetic Care for the Financially Disadvantaged. (1977). Journal of fhe Americun Dental Associaiion, 77, 1024- 1038. HARWOOD, bridge, MA.:
A. (Ed.). (1981). Ethnicily Harvard University Press.
KISSAM,
cure. Cam-
E., & INTILI, J. (1888). Preliminary results, California HuCorporation survey of legalization applicants. Rosa. CA: Author.
nmn Development
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PASSEL, 181-191.
J. (1986). Undocumented
TUNG, T. (1980). Indochinesepatients. South East Asians.
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