The United States has been a destination for immigration since the 1800’s. The amount of immigration has fluctuated over time but has steadily increased since 1965 when the Immigration Act of 1965 allowed for more mass immigration by abolishing the quota system previously used to control immigration to the United States. According to American Community Survey data from 2016, 13.5% of the total population in the United States is accounted for by immigrants and immigrants and their U.S. born children make up 27% of the total population (Zong, Batalova, & Hallock, 2018). In 2016 specifically, 1.49 million immigrants moved to the United States which was a 7% increase than the previous year (Zong, Batalova, & Hallock, 2018). In terms of the top countries of origin for immigrants to the U.S.; India, China, Mexico, Cuba, and the Philippines make up the top five (Zong, Batalova, & Hallock, 2018). Immigration is a highly debated topic in U.S politics but despite anti-immigrant sentiment in recent years, immigration to the U.S has not slowed and there remains a large percentage of the current U.S. population that is foreign-born. In fact, the immigrant population is growing faster than the U.S. born population as the number of foreign born in the U.S. grew 3.4 times over a three decade period (1970-2000) compared to the total U.S. population which grew 1.4 times (Lum & Vanderaa, 2009).
The immigrant population in the United States is older than the U.S.-born population, with an median age of 44.4 years compared to 36.1 years for the U.S.-born according to the 2016 data (Zong, Batalova, & Hallock, 2018). At 15%, elderly immigrants make up the second highest percentage of the immigrant population in the U.S., which is the same as the percentage of U.S. born elderly in relation to the U.S.-born total population (Zong, Batalova, & Hallock, 2018). As immigration continues to rise, the elderly immigrant population will also increase. The percentage of U.S.-born elderly is also increasing due to the aging of the baby boomer generation. By 2035, 20% of the United States population will be made up of adults aged 65 and older, outnumbering children under age 18 for the first time in the history of the United States (Lynott, Harrell, Guzman, & Gudzinas, 2018). These older adults will be living longer than previous generations as well. This is a major concern for the healthcare industry as the current system is not set up to care for such an increase in the elderly population with respect to the sheer number of physicians and caretakers needed and the amount of money needed to provide care for this population based on the rate the U.S. is spending now. The immigrant subset is an especially vulnerable part of this elderly population due to numerous health disparities compared to U.S.-born elderly, on top of accessibility barriers to acquiring health insurance coverage in the United States as an immigrant. Of the immigrant population in 2016, 56% had private insurance, 30% had public insurance, and 20% were uninsured, while only 7% of the U.S.-born population was uninsured (Zong, Batalova, & Hallock, 2018). Therefore, in the discussion of how to improve the care of the growing older adult population in the United States, it is imperative to include the needs of the elderly immigrant population to decrease the health disparities currently seen in this population and to be better equipped to deal with them in the future.
There are numerous health disparities that present in a clinical manner regarding elderly immigrant health. These health issues present differently based on gender, race, where the elderly immigrant came from initially, how long the elderly immigrant has been in the United States, and immigrant status. A study from 2009 investigated the association of immigrant status among older people to their physical and mental health outcomes, among other variables (Lum & Vanderaa, 2009). In general, there is little research on immigrant health and what research has been done has had small sample sizes, based on small communities in specific areas. This study was one of the first to provide a broader overview of the health status of elderly immigrants in the United States. Using data from the Asset and Health Dynamic of the Oldest Old study (AHEAD), they found that immigrant status was associated with poorer self-reported health status higher depression levels, and number of daily living activities (ADL) and instrumental activities of daily living (IADL) difficulties (Lum & Vanderaa, 2009). Among the immigrant population, black and Hispanic elderly immigrants reported poorer self-reported health status and had higher levels of depression than white elderly immigrants. Comparing racial groups, black and Hispanic elderly immigrants had worse self-reported health status and higher levels of depression than native-born elderly black and Hispanic people, showing the effect of combined effect of identifying as a racial minority as well as an immigrant (Lum & Vanderaa, 2009). Elderly immigrants who had moved to the United States as older adults (51 years and older) had worse health outcomes than elderly immigrants who had moved to the U.S. when they were younger. Elderly immigrants were also less likely to have Medicare or insurance coverage in general, outpatient surgery, and dentist visits than native-born elderly (Lum & Vanderaa, 2009). These correlations remained statistically significant even after adjusting for variables of gender, income, and education. The authors of this study did mention they were limited by not having access to refugee status of the immigrant populations so were unable to examine the effect refugee status has on mental and physical health and that they did not address differences in health disparities between genders (Lum & Vanderaa, 2009). Despite these limitations, this study clearly shows major health disparities in terms of mental and physical health between immigrant and native-born elderly populations in the United States and proves there is a problem here that needs to be addressed.
There has been much more research done specifically on the health status of the elderly Asian immigrant population in the United States. According to 2012 census data, 10% of the Asian American immigrant population in the United States is age 65 or older (Yoo, Musselman, Lee, & Yee-Melichar, 2014). Among all subgroups of elderly Asian immigrants in the United States exist higher rates of cancer which is partially caused by decreased access to preventive screenings and less continuous care through the progression cancer diagnoses. Heart disease, which is the top cause of death for people in the United States, is diagnosed less in elderly Asian immigrant populations, despite observations that Asian immigrants tend to be less physically active, have higher rates of diabetes than white Americans, and have high rates of death from this disease (Yoo, Musselman, Lee, & Yee-Melichar, 2014). Elderly Asian immigrants also have the highest rates of suicide than Hispanics or African Americans, for whom suicide rates decrease with age. This is supported by data showing extremely high rates of depression among elderly Asian immigrant subgroups combined with some of the lowest rates of use of mental health services (Yoo, Musselman, Lee, & Yee-Melichar, 2014). A study published in 2006 specifically focused on depression in Korean elderly immigrants, showing that only 16% of the population they worked with reported none of the depressive symptoms tested (Han, Kim, Lee, Pistulka, & Kim, 2007). Another study done with Chinese elderly immigrants observed the decreased use of mental health services in this population, with most elderly immigrants reporting that they rely on themselves rather than professionals for problems with mental health (Aroian, Wu, & Tran, 2005). Finally, a third study done on multiple subgroups of elderly Asian immigrant populations in New York City showed higher rates of depression and more stressful life events in Chinese elderly immigrants than Korean elderly immigrants, but both subgroups had worse health outcomes than U.S.-born elders (Mui, Kang, Kang, & Domanski, 2007). These studies show that it is important to break down this population into subgroups as there are different outcomes for different Asian nationalities. However, there is clearly an overarching disparity among elderly Asian immigrants especially, regarding mental health.
Another aspect of elderly immigrant health involves the idea of acculturation. Acculturation is typically defined as “an individual-level process through which individuals acquire the behaviors, attitudes, and values prevalent within American society” (Viruell-Fuentes, Miranda, & Abdulrahim, 2012). While it has been observed that most immigrants arrive in the United States in good health and sometimes have more positive health statuses compared to their native-born counterparts, this phenomenon disappears after they have lived in the United States for ten to twenty years and in subsequent generations (Markides, 2014). This observation has been attributed to acculturation as immigrants acquire negative health behaviors, often relating to diet and physical activity, that exist in American lifestyles over time. Research has been done specifically on obesity levels, showing that immigrants arrive in the United States with significantly lower obesity levels than their native-born counterparts but after ten years, women converged to the native obesity levels and after fifteen years, men converged to the native levels by one third (Markides, 2014). Additional research has been done that shows disability levels converging in black immigrants compared to native-born black people (Markides, 2014). While many scholars attribute these observations to acculturation, some scholars warn against using culture, arguing that solely cultural explanations hide the effects of social inequalities and larger structural factors in the United States that work through intersectionality to produce health inequalities among immigrants (Viruell-Fuentes, Miranda, & Abdulrahim, 2012). Whatever lens through which we view this phenomenon, it is clear that the health disparities observed in immigrant populations are often produced or are worsened in the United States, and this effects elderly immigrants as well.
As the literature shows, the elderly immigrant population is incredibly diverse. People are immigrating to the United States from all over the world. The health issues facing communities of immigrants from different countries are also diverse. Immigrants from different countries have various barriers to care including language barriers, structural racism due to skin color differences, clashes with Western medical ideals of what healing practices should entail, and access to jobs and social services that provide health benefits because of immigrant status. Many of the social issues immigrants face lead to stress which negatively impacts physical and mental health. Therefore, in order to fix this problem of health disparities in elderly immigrants, the solutions will need to be diverse, able to reach many different identities and backgrounds, and be socially, as well as clinically, based.
Currently, there are a few intervention strategies that have already been put in place to attempt to help decrease the negative health statuses of elderly immigrants in the United States. A specific example is the Promotora Program at Puentes de Salud, a free clinic for Latinx immigrants to Philadelphia. Puentes de Salud takes a holistic approach to treating their patient population, which means that not only do they provide medical care, they have a variety of programs that promote health in social ways. The Promotora Program does just that; it trains members of the community to work as community health workers, or promotoras, to work with the rest of the community on promoting lifestyle choices that influence health positively (Zylberberg, 2010). These promotoras lead workshops and give advice to their peers on diabetes prevention, obesity and nutrition, HPV vaccination, and prenatal care. Using community work
There are important and unique challenges of working with immigrants that must addressed when evaluating this issue. Many of these challenges relate to ethical conflicts between cultures of healing in the United States compared to the countries where immigrants are coming from. The ideals and values of Western medicine often conflict with traditional medicine practices in many other cultures specifically regarding the cause of medical illnesses. In Western medicine, illness is viewed as biologically based and treatments are designed to specifically target the biological pathway that is causing the problem (Pavlish, Noor, & Brandt, 2010). Elderly immigrants have grown up believing in their own ideas of what causes illness and their own healing practices and have had little time to understand or adjust Western medicine compared to younger immigrants, and especially compared to people born in the United States. A study done with Somali immigrant women showed that they perceived their illnesses more holistically, believing that explanations for their illnesses included spiritual dissonances and lifestyle disconnections (Pavlish, Noor, & Brandt, 2010). Therefore, elderly immigrants can be resistant to treatments provided to them by doctors in the United States. Doctors often view this as noncompliance and end up treating these patients with disregard since they think that the patients simply do not want to do what they prescribed. However, this is not necessarily true. In some cases where the patient does not speak English, which is another challenge to working with elderly immigrants, the patient may not fully understand the importance of following the treatment plan prescribed by the doctor or the instructions were not explained clearly enough. About 49% of the immigrant population in 2016 was Limited English Proficient and elderly immigrants are more likely to only speak their native language (Zong, Batalova, & Hallock, 2018). Interpreters are extremely important in elderly immigrant healthcare due to these language barriers. However, there are challenges to finding and using interpreters. Oftentimes the interpreter will be another family member who might speak English to some degree. This creates conflicts between family members who may be uncomfortable talking about another family member’s medical issues or may not know how to translate specific medical jargon to the patient. There are also ethical considerations for professional interpreters regarding translation omittances or additions that may not leave the doctor and the patient on the same page.
It is also a possibility that patients are not comfortable talking to the doctor because of the power imbalances in play. For elderly immigrants it may be difficult to find a doctor who looks like them, speaks their language, and understands their culture and the difficulty of immigrating to a new country. This can easily create a divide between the patient and the doctor where the patient ends up not feeling able to open up and talk about their concerns and so the real medical problems go untreated. A final reason elderly immigrants may not feel comfortable accessing medical care in the United States could be due to the fear for their own safety in a country where there is increasingly more anti-immigrant sentiment in politics and in the general population. Obviously some immigrant statuses unfortunately lack the ability to obtain insurance coverage. Many of these people end up accessing emergency room services but even still push off going to the emergency room due to fear of being turned away or being targeted for deportation at or on the way to and from the facility (Boyd-Barrett, 2018). Especially for elderly immigrants, who may not be able to drive themselves to hospitals, taking public transportation makes themselves even more visible to potential targeting. Even if this is not the case for communities and hospitals around the country, the heightened hostility towards immigrants that creates this increased concern for personal safety is certainly a challenge in addressing the health needs of elderly immigrants.
There are also opportunities present in evaluating this problem. One important opportunity is lowering the amount of money the United States spends on health care. Since many immigrant statuses do not allow immigrants to access public health insurance, many elderly immigrants do not have the necessary coverage to access preventive and regular medical services. Therefore, they end up going to emergency rooms when they cannot ignore their medical problems anymore, which costs more than if the problem had been dealt with earlier on. Fixing this issue could help to decrease the high expenditures on healthcare in the United States overall. Another opportunity involves the health of subsequent generations and immigrant communities as a whole. By improving elderly immigrant health outcomes, this improved health could be passed down in their families and improve immigrant health overall. Especially if the interventions to improve elderly immigrant health involve creating more community health programs, this would involve younger members of the immigrant community as well, making more people aware of health opportunities and practices and enabling communities to work together and support each other. Improving the health of such a large population in the United States would open up opportunities to this underserved group and increase productivity and the overall health of the country.
Healthcare professionals, including doctors and social workers, have valuable roles and opportunities in thinking about how to solve this issue.
In thinking about all the unique aspects that need to be taken into consideration in relation to this issue, a few glaring holes stood out that if addressed, would help decrease health disparities for elderly immigrants in the United States. The first relates to health care policy. For undocumented immigrants living in the U.S., there is no access to public health insurance or any of the social security or disability benefits that U.S.-born older adults are able to take advantage of. Prior to the 1996 Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA), some undocumented immigrant workers could access government benefits but even if this were repealed, it may not apply to elderly immigrants if they cannot work anymore (Angelari, 2008). This represents a huge disparity that causes poor health outcomes in elderly immigrants compared to the U.S.-born elderly population because many immigrants simply cannot pay for or access any health care. Therefore, they do not go to the doctor when they need to, they are not able to utilize a lot of preventive services or primary care, they are forced to keep working in physically demanding jobs, and this causes medical problems to pile up until it comes to emergency situations. This also costs the U.S. a lot of money in emergency room visits and emergency care, on top of the ethical consideration that anyone should be able to access healthcare regardless of citizenship status without fearing that their livelihood will be taken away if they try to access medical care. Since the Affordable Care Act was implemented, the immigrant uninsured rate dropped from 32 to 20 percent with noncitizen immigrants showing the greatest drop from 46 to 32 percent compared to the naturalized immigrants drop from 16 to 8 percent (Zong, Batalova, & Hallock, 2018). However, 20% is still a large portion of the immigrant population in the United States and the U.S. should continue to work towards lessening this number.
Another big issue, and a potential way start to solving the issue of access to healthcare, is the lack of foreign-born doctors in the healthcare system in the United States. Doctors in the U.S. are in a position of power and have the ability to affect the laws and policy regarding access to healthcare. Having more people from other countries training to be a doctor and practicing in the U.S., sympathetic to the plight of elderly immigrants, would create a more widespread understanding and urge to do something among the medical community and would push the government more to establish new policies about access to healthcare. Another effect this would have is it would generate more research on the health needs of elderly immigrant and immigrant populations in general, devoting more resources to this area of study to increase our understanding of what this population is suffering from and what we can do to alleviate that. To change the demographics of medical school matriculants in this way, U.S. medical schools need to be made more accessible to international students and immigrants living in the United States. Right now, many medical schools do not accept international students and the schools that do only accept a very small number and require them to show they can pay the exorbitantly high cost of all four years of medical school in full and up front. This is an extreme deterrent to immigrants who may not be able to apply for federal aid to attend medical school or for international students who, for the most part, cannot get in to these schools. Increasing the diversity and cultural humility of the doctors practicing in the United States, as well as creating more community based health promotion programs as discussed earlier, would help to decrease the health disparities currently faced by many elderly immigrants and increase the quality of life for many generations.