Social Determinants of Immigrant’s Health: Immigrant health paradox, State policy contents, and Access to care
Restricted (Penn State Only)
- Author:
- Kim, Gunah
- Graduate Program:
- Public Administration
- Degree:
- Doctor of Philosophy
- Document Type:
- Dissertation
- Date of Defense:
- June 10, 2024
- Committee Members:
- Goktug Morcol, Professor in Charge/Director of Graduate Studies
Jonathan Ivy, Outside Unit & Field Member
Dan Mallinson, Major Field Member
Younhee Kim, Chair & Dissertation Advisor
Sungwoog Choi, Major Field Member - Keywords:
- Immigrant health
Immigrant policy
Health equity
Maternal and infant health
Prenatal care initiation
Social determinants of health
Access to care - Abstract:
- The current maternal health crisis highlights that persistent health disparities in health care utilization and health outcomes exist by nativity and immigration status. Furthermore, recent anti-immigrant rhetoric and policies have raised concerns about the health disparities experienced by immigrant populations. This two-essay dissertation aims to examine whether and to what extent state-level immigrant policy contexts affect the access to care among immigrant pregnant women. To achieve this, this study utilizes national population-based data from the National Center for Health Statistics with state characteristics collected by my analysis of multiple sources. Multivariate regression is employed to examine the association between state immigrant policies and access to prenatal care among immigrant populations. To address current theoretical and methodological research gaps, this study introduces an innovative approach within the public health and social determinants of health framework, alongside a policy bundle approach to capture variations in policy design and implementation intensity. The findings from this research contribute to the literature on social equity and immigration policy in public administration, as well as health equity and social determinants of health in health administration, offering insights into the complex dimensions of health inequities affecting immigrant populations. The first chapter discuss disparities in maternal health and uses a social equity lens to highlight issues related to access to care for historically underrepresented group, immigrant populations. It discusses the immigrant health paradox, where longer residency in the U.S. correlates with less favorable health outcomes, focusing on institutional factors related to anti-immigrant rhetoric and policies. The chapter also presents a theoretical framework for social determinants of health and outlines the data and methods used in subsequent chapters. The second chapter aims to analyze the association between states’ policy adoption supporting immigrant populations and their use of health services. In particular, this chapter aims to estimate the effects of state policy adoptions to expand Medicaid/CHIP eligibility to immigrant pregnant women on their access to care in the United States. The federal welfare and immigration reform in 1996 restricted the eligibility of immigrants for public health insurance like Medicaid and CHIP. As of January 2023, 34 states adopted at least one policy option to expand Medicaid/CHIP eligibility for immigrant pregnant women. To achieve this, a difference-in-differences approach was adopted to analyze the effects of the eligibility expansion on prenatal care service utilization (first difference) between publicly insured and uninsured immigrants (second difference) in 50 states and the District of Columbia. In addition to the static a difference-in-differences specifications, this study conducts sensitivity analyses to check the violation of the parallel trend assumption based on the states with Medicaid expansion under Affordable Care Act (ACA hereafter). The main data source of the essay is 2015-2019 Natality files from the National Center for Health Statistics. All singleton births satisfying the following conditions were included in this essay: 1) mother’s nativity is outside the United States; 2) mother’s age is 15-44; 3) uninsured or publicly insured; 4) born in a hospital located in 50 states and the District of Columbia. The empirical results show that state policy adoptions to expand eligibility were associated with the improved access to prenatal care services among immigrant pregnant women and thus, restoring eligibility for Medicaid and CHIP to legal immigrant pregnant women who were cut off by welfare and immigration reform in 1996 was associated with use of health services. The third chapter aims to examine states’ distinct policy contexts and their impact on immigrants’ health service utilization. To do so, this chapter introduces a new public health approach focusing on the concurrent mechanisms of both supportive and restrictive immigration policies. Then, this chapter applies the policy bundle approach which is useful for classifying the characteristics of diverse policy contexts and for leveraging policy variations by states so as to assess their differential impact on immigrants’ health service utilization. After generating immigration policy bundle, this study revisits the prenatal care utilization of immigrant populations in the previous chapter and estimate the impact of each immigration policy bundle by using fixed effects logistic regression models including fixed effects. The main data source of the essay is 2016-2022 Natality files from the National Center for Health Statistics. The sample of this study includes all singleton births by foreign-born birthing people aged 15-44 which born in a hospital located in 50 states and the District of Columbia. The findings indicate that education policies offering in-state college tuition and financial aid to immigrants, irrespective of their citizenship status, were significantly associated with improved access to prenatal care while policies related to public health benefits, labor and employment, or law enforcement did not significantly affect access to prenatal care. Furthermore, there is no evidence to support that the overall state policy climate was associated with improvements in access to prenatal care. Through its various analyses, this dissertation addresses existing research gaps on public policies and immigrant health. First, this dissertation answer calls for research to explore whether those can enhance health service utilization or mitigate the adverse effects of restrictive policy environments. Second, this dissertation provides a comprehensive overview of immigrants’ health by examining the impacts of different immigrant policy contexts by state. Third, this dissertation employs the social determinants of health framework to investigate the long-term health effects of non-health policies on immigrant populations, which has been less examined. Fourth, this dissertation utilizes the policy bundle approach to capture the heterogeneity in policy design and the intensity of policy implementation, thereby laying the groundwork for future research to address current methodological challenges in the study of social determinants of health. In this way, this dissertation contributes to the existing literature on public policy and immigrant health from both theoretical and methodological perspectives.