Changes in Health Insurance Coverage Over Time by Immigration Status Among US Older Adults, 1992-2016

Key Points

Question

Does health insurance coverage over time differ between recent immigrant, early immigrant, and nonimmigrant adults in the US?

Findings

In this cohort study of 9691 US adults, recent immigrants were 15% less likely than nonimmigrants to have insurance coverage at baseline, but this disparity was eliminated over the 24-year follow-up period in association with large increases in public insurance.

Meaning

These findings suggest that public insurance programs such as Medicare play a prominent role in reducing disparities in insurance coverage for recent immigrants compared with nonimmigrants.

Abstract

This cohort study compares longitudinal changes in insurance coverage over 24 years of follow-up between recent immigrant, early immigrant, and nonimmigrant adults in the US.

Abstract

Importance

Disparities in health insurance coverage by immigration status are well documented; however, there are few data comparing long-term changes in insurance coverage between immigrant and nonimmigrant adults as they age into older adulthood.

Objective

To compare longitudinal changes in insurance coverage over 24 years of follow-up between recent immigrant, early immigrant, and nonimmigrant adults in the US.

Design, Setting, and Participants

This population-based cohort study used data from the nationally representative Health and Retirement Study. Data were collected biennially from 1992 to 2016. The population included community-dwelling US adults born between 1931 and 1941 and aged 51 to 61 years at baseline. Statistical analysis was performed from February 3, 2017, to January 10, 2020.

Exposures

Participants were categorized as nonimmigrants (born in the US), early immigrants (immigrated to the US before the age of 18 years), and recent immigrants (immigrated to the US from the age of 18 years onward).

Main Outcomes and Measures

Self-reported data on public, employer, long-term care, and other private insurance were used to define any insurance coverage. Longitudinal changes in insurance coverage were examined over time by immigration status using generalized estimating equations accounting for inverse probability of attrition weights. The association between immigration status and continuous insurance coverage was also evaluated.

Results

A total of 9691 participants were included (mean [SD] age, 56.0 [3.2] years; 5111 [52.6%] female). Nonimmigrants composed 90% (n = 8649) of the cohort; early immigrants, 2% (n = 201); and recent immigrants, 8% (n = 841). Insurance coverage increased from 68%, 83%, and 86% of recent immigrant, early immigrant, and nonimmigrant older adults, respectively, in 1992 to 97%, 100%, and 99% in 2016. After accounting for selective attrition, recent immigrants were 15% less likely than nonimmigrants to have any insurance at baseline (risk ratio, 0.85; 95% CI, 0.82-0.88), driven by lower rates of private insurance. However, disparities in insurance decreased incrementally over time and were eliminated, such that insurance coverage rates were similar between groups as participants attained Medicare age eligibility. Furthermore, recent immigrants were less likely than nonimmigrants to be continuously insured (risk ratio, 0.89; 95% CI, 0.85-0.94).

Conclusions and Relevance

Among community-dwelling adults who were not age eligible for Medicare, recent immigrants had lower rates of health insurance, but this disparity was eliminated over the 24-year follow-up period because of uptake of public insurance among all participants. Future studies should evaluate policies and health care reforms aimed at reducing disparities among vulnerable populations such as recent immigrants who are not age eligible for Medicare.