Zoya ResizeDr. Zoya Gubernskaya is an assistant professor in the Department of Sociology and the Center for Social and Demographic Analysis (CSDA) at the University at Albany, SUNY. Her current research aims at better understanding of health and wellbeing of older immigrants in the United States.

ElderBranch interviewed Dr. Gubernskaya to discuss her recently published paper (Un)Healthy Immigrant Citizens Naturalization and Activity Limitations in Older Age, which she wrote along with Dr. Frank D. Bean of the University of California, Irvine and Dr. Jennifer Van Hook of Pennsylvania State University.

Why did you decide to examine the relationship between naturalization and activity limitations in older adults? Why is this topic important?

I am interested in studying health and well-being of older immigrants. To be more specific, I am trying to understand how immigrants’ incorporation experiences are related to their health and well-being in old age.

There is substantial research on immigrant incorporation that generally finds that as foreign-born individuals spend more time in the country, they learn English and improve their socio-economic status. And there is the “immigrant health paradox” literature that finds that most immigrants are healthier than the native-born when they come to the U.S., but over time this health advantage becomes smaller and disappears completely. Given that socio-economic resources are strongly related to positive health outcomes, these research findings seem contradictory.

Although this particular study addresses a relatively narrow question, it is a step toward better understanding of the relationship between immigrant incorporation experiences and health in later life.

Please describe your study. What were your in-going hypotheses?

Naturalization is one of the indicators of immigrant incorporation, and since incorporation is associated with improved socio-economic resources and the resources are linked to good health, I expected to find better health outcomes among the foreign-born who had naturalized. But, since the 1996 welfare reform, citizenship has become one of the conditions for receiving Medicaid, thus creating an incentive for low-income foreign-born individuals with health problems or disabilities to naturalize in order to get access to public health insurance. The more I thought about this, the clearer it became that the relationship between naturalization and health depends on another important factor related to both incorporation and health – the age at migration.

Older immigrants are an extremely diverse group. Most researchers are well aware of the differences between the foreign-born by country of origin, but they tend to overlook the differences by age at migration. Of course, incorporation doesn’t happen universally and seamlessly for every immigrant, but those who come to the U.S. as children or young adults have more opportunities to incorporate into the U.S. society compared to those who come in advanced age. And of course, the great majority of the foreign-born in the U.S. arrive as young adults. However, there is a sizeable and increasing group of the foreign-born who come in advanced age primarily through the family reunification provision of the current immigration policy. These immigrants have much fewer opportunities to become incorporated due to their age; they are often economically dependent on their adult children. Based on scarce empirical research on this group, many older immigrant newcomers speak little or no English and lack access to healthcare.

Thus, I still expected to find the protective effect of citizenship on health in later life, but only among those who migrated as children or young adults. Among those who migrated in later life, I expected to find no protective effect of citizenship. If anything, I expected to find that among these late life immigrants a so called “negative health selection into citizenship” – the tendency to naturalize at higher rates among those older foreign-born who experience health problems to ensure access to public healthcare.

What were the key findings from your research?

Among those who migrated as children and young adults, citizens have lower rates of functional limitations than the non-citizens. It is likely that the tangible and intangible benefits associated with citizenship have positive effect on health of the foreign-born.

Those who migrated after age 50 have higher rates of functional limitations compared to those who migrated at younger ages, and, among this group, citizens have higher rates of functional limitations than non-citizens. Older immigrant newcomers with health problems are more likely to naturalize, most likely to gain or preserve access to healthcare. 

Supporting this interpretation, both effects are stronger for those who naturalized fast (defined as within 10 years of arrival).

Finally, the “negative health selection” into naturalization among those who arrive in advanced age became stronger after 1996. This finding suggests that the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) legislation indeed limited access for non-citizens and put at risk those foreign-born individuals who happened to become sick before becoming a U.S. citizens.

What healthcare and immigration policy implications do your findings have?

The family reunification provision of the immigration policy makes it relatively easy for parents of the naturalized citizens to join their children in the U.S. Once in the U.S., however, as most other foreign-born individuals, except for refugees, these immigrants are left to fend for themselves. But, unlike younger immigrants, many of the newly arrived older foreign-born individuals have health problems, and generally they are at the age when access to healthcare is crucial. However, buying private health insurance for an elderly person can be prohibitively expensive even for middle-class adult children, especially if a parent has a precondition. So there is a tendency among this specific group of immigrants to rely on the public healthcare programs such as Medicaid and Medicare, for which they are not eligible during their first 5 years in the country. Moreover, many foreign-born individuals do not apply for Medicaid even after spending 5 years in the country because they worry they will be denied citizenship. That is why they prefer to naturalize first.

Even though some people would argue that we need to stop immigration of elderly parents, I believe that at the very least a more careful cost-benefit analysis is needed before making this recommendation. This is not an easy thing to do because it requires taking into account things like remittances that children would send to their parents, unpaid labor that older immigrants do in their children’ households (childcare, cooking, cleaning), not to mention non-monetary factors such as “keeping families together” and “global health,” which are extremely difficult to quantify.

I would argue that fixing a dysfunctional health insurance market so that older non-citizens with possible pre-conditions are able to buy health insurance without putting their children’s families at risk of bankruptcy will mitigate the problem, at least to some degree. Hopefully, Obamacare is a step in the right direction.

Also, the 5-year-ban on access to public healthcare programs might not be cost-effective in the long run as untimely diagnostics is likely to result in more expensive treatment later on.

Besides improving access to healthcare, it is important to develop programs to help older immigrant newcomers adjust to their new country and become active members of their community (e.g. organize support groups, cultural events, English language lessons, computer literacy programs, help with transportation, help with navigating the bureaucracy, etc).

For those who came to the U.S. as children or young adults, legal status seems to be protective of health in later life. So creating a path to citizenship for the undocumented immigrants will, among other things, likely to improve population health.

Based on your findings, what recommendations would make to healthcare providers who have older adult patients who are immigrants?

Knowing at what age an immigrant came to this country is more important than the place of birth and even the number of years he or she spent in the United States. Older immigrants arriving after age 45-50 have higher rates of functional limitations (and probably other health problems) compared to the native-born or those who immigrated at a younger age. So the risk factor is not a foreign-born status per se, but older age at migration.

Older immigrant newcomers often lack health insurance, but they need to be aware that citizenship is not a necessary condition to receive federal health insurance. After spending 5 years in the country as legal permanent residents, foreign-born immigrants become eligible for Medicaid (if they have limited income, are over age 65 or have a disability) and Medicare Part A (if they are age 65 and over). Some states have additional programs that cover even those foreign-born who spent less than 5 years in the country.

What are the next steps in terms of furthering the research in this area? What questions still need to be answered?

It is important to assess whether the 5-year-ban on access to the federal health programs for the foreign-born is cost-effective.

It is important to look at other health measures to see if the same pattern of association between naturalization and health by age at arrival holds, for example, for other indicators, such as mental health or chronic conditions.

It is also important to understand the mechanisms behind the protective effect of naturalization on health of those elderly immigrants who arrived as children or young adults. It could be access to a safety net and health insurance during the periods of low income and unemployment; better employment opportunities; eligibility for college loans and fellowships; or improved psychological wellbeing derived from the sense of belonging that comes with citizenship. It could be that all these factors matter. It also could be that the real divide is between the permanent residents (including citizens) and all other foreign-born individuals, or between the legal and undocumented immigrants. Unfortunately, we often don’t have good data to look at these important differences.

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