August 2005, Vol 95, No. 8 | American Journal of Public Health Mohanty et al. | Peer Reviewed | Research and Practice | 1431
RESEARCH AND PRACTICE
Objectives. We compared the health care expenditures of immigrants resid-
ing in the United States with health care expenditures of US-born persons.
Methods. We used the 1998 Medical Expenditure Panel Survey linked to the
1996–1997 National Health Interview Survey to analyze data on 18398 US-born
persons and 2843 immigrants. Using a 2-part regression model, we estimated total
health care expenditures, as well as expenditures for emergency department
(ED) visits, office-based visits, hospital-based outpatient visits, inpatient visits,
and prescription drugs.
Results. Immigrants accounted for $39.5 billion (SE=$4 billion) in health care
expenditures. After multivariate adjustment, per capita total health care expen-
ditures of immigrants were 55% lower than those of US-born persons ($1139 vs
$2546). Similarly, expenditures for uninsured and publicly insured immigrants
were approximately half those of their US-born counterparts. Immigrant chil-
dren had 74% lower per capita health care expenditures than US-born children.
However, ED expenditures were more than 3 times higher for immigrant chil-
dren than for US-born children.
Conclusions. Health care expenditures are substantially lower for immigrants
than for US-born persons. Our study refutes the assumption that immigrants
represent a disproportionate financial burden on the US health care system.
(Am J Public Health. 2005;95:1431–1438. doi:10.2105/AJPH.2004.044602)
Health Care Expenditures of Immigrants in the United States:
A Nationally Representative Analysis
| Sarita A. Mohanty, MD, MPH, Steffie Woolhandler, MD, MPH, David U. Himmelstein, MD, Susmita Pati, MD, MPH, Olveen Carrasquillo, MD, MPH,
and David H. Bor, MD
In this study, we used nationally representa-
tive data to compare the health care expendi-
tures of immigrants and US-born individuals.
We analyzed data from the Agency for
Healthcare Research and Quality’s 1998
Medical Expenditure Panel Survey (MEPS).
This survey is designed to provide nationally
representative estimates of expenditures and
health services for the US civilian noninstitu-
tionalized population.1 4To provide estimates
for specific priority populations, MEPS over-
samples low-income families and ethnic mi-
norities. MEPS data are compiled through in-
formation obtained from the Household
Component, the Medical Provider Compo-
nent, and the Insurance Component of MEPS.
In the MEPS Household Component, respon-
dents use a computer-assisted program to re-
port sociodemographic characteristics, health
and functional status, use of medical care ser-
vices, health insurance coverage, income, and
employment. The MEPS Medical Provider
Component supplements and validates infor-
mation on medical care events reported in
the Household Component by contacting pro-
viders and facilities identified by household
respondents. The Medical Provider Compo-
nent includes expenditure data from hospitals,
outpatient medical providers, home health
agencies, and pharmacies.
We analyzed total health expenditures dur-
ing 1998, including expenditures for several
specific population subgroups and categories
of health care. MEPS defines expenditures as
the sum of payments for care provided during
1998. This figure includes payments such as
out-of-pocket payments, insurers’ payments,
and imputed payments for free care received
in public hospitals or clinics. The Agency
for Healthcare Research and Quality uses
weighted sequential hot-deck imputation15for
any missing values (for a respondent with
missing data, values are imputed from the
nearest preceding respondent in the sequence
The United States is a nation of immigrants. In
2000, the immigrant population of the United
States was 28.4 million, 10.4% of the total
population.1In one of the most comprehensive
analyses to date on the costs and benefits of
immigrants to the US economy, the National
Research Council concluded that immigrants
add as much as $10 billion to the economy
each year and that immigrants will pay on
average $80000 per capita more in taxes than
they use in government services over their life-
times.2The Social Security Administration esti-
mates that workers without valid social secu-
rity numbers contribute 8.5 billion dollars
annually to Social Security and Medicare. Such
workers, most of them immigrants, usually re-
ceive no eligibility credits for their contribu-
tions.3Taxpayers and politicians in states such
as New York, California, Texas, Arizona, and
Florida have expressed concern about the
potential extra burden immigrants place on
their states’ health care systems,5–8particularly
state welfare and Medicaid programs.9
Researchers from the Center for Immigra-
tion Studies have concluded that because im-
migrant labor has “limited value . . . in an
economy that increasingly demands educated
workers,” providing insurance to immigrants is
“at the taxpayer expense.”10These views have
resulted in legislative initiatives such as Cali-
fornia’s Proposition 181, which attempted (be-
fore it was ultimately overturned in court) to
bar undocumented immigrants from receiving
nonemergency health services.1 1Similarly, the
1996 Personal Work and Responsibility Rec-
onciliation Act made most legal immigrants
who entered the United States after 1996 in-
eligible for Medicaid for 5 years after entry.12
Although more recent surveys suggest that
public attitudes toward immigrants’ contribu-
tions, particularly with regard to economic
impact, are becoming more positive,13public
fears after September 2001 may reverse this
American Journal of Public Health | August 2005, Vol 95, No. 8 1432 | Research and Practice | Peer Reviewed | Mohanty et al.
RESEARCH AND PRACTICE
who has similar characteristics and complete
information).16MEPS combines facility and
physician expenses when tabulating emer-
gency department, hospital-based outpatient,
and inpatient expenditures. Payments for
over-the-counter drugs and for alternative
medicine (e.g., acupuncture, chiropractic care)
are not included in MEPS. MEPS expenditure
estimates exclude costs for health care admin-
istration and institutionalized care. However,
after adjustment for these omissions, MEPS
estimates of national health expenditures sub-
stantially agree with those of the US Depart-
ment of Health and Human Services’ National
Health Accounts.1 7
MEPS expenditure data include estimates
of free care and bad debt in public hospitals
or clinics. These imputed expenditure data
are designed to account for payments, made
from government budgets, that are not tied to
specific patients. However, MEPS expenditure
data do not cover uncollected liabilities, nego-
tiated discounts, bad debt, and free care asso-
ciated with private providers.15By some esti-
mates, US hospitals (public and private) write
off as much as $2 billion a year in unpaid
medical bills to treat illegal immigrants.18
Therefore, we performed a separate confir-
matory analysis of MEPS total charges (rather
than expenditures) for health care, which in-
clude free care delivered at any site. Charge
variables should be interpreted with caution,
because they do not represent actual dollars
exchanged for services or the resource costs
of those services.15
To obtain data on the immigration status of
respondents, we combined the Household
Component file of the 1998 MEPS with the
1996–1997 National Health Interview Sur-
vey (NHIS), which asked respondents about
their place of birth. Each year, MEPS draws a
new panel from the previous year’s NHIS
sample. The NHIS includes self-reported data
on place of birth as well as on a variety of
other sociodemographic and household char-
acteristics not included in the MEPS. As de-
scribed elsewhere,19NHIS and MEPS data
sets can be linked. In 1998, MEPS sampled
24072 individuals and assigned positive
person-level weights for 22953 individuals.
We were able to link 21241 individuals in
the MEPS sample (18398 US-born persons
and 2843 immigrants) with the NHIS sample.
Individuals sampled in MEPS were not linked
with the NHIS sample (or did not receive a
person-level weight) if they were not a mem-
ber of an NHIS household at the time of the
1996–1997 NHIS interview but had entered
the household by the time of the MEPS inter-
view (e.g., newborns; those returning from
military service, college, or travel; those newly
married or moving into a new household).
We found that when these files were
linked, 7.4% of the MEPS sample was omit-
ted. This factor remains a limitation of the
MEPS–NHIS merge, because no weighting
adjustment was made for these missing indi-
viduals. Despite this limitation, the merging of
these 2 national data sets is an accepted
methodology.20An individual was defined as
US born if he or she was born in one of the
50 states or the District of Columbia. All oth-
ers were classified as foreign born. Foreign-
born persons included naturalized citizens,
permanent residents, visa holders, refugees,
and undocumented immigrants. However,
data on specific resident categories were not
provided in the NHIS. For the purposes of
this study, the terms “foreign born” and “im-
migrant” were considered to be synonymous.
To obtain nationally representative esti-
mates, we used person-level weights (which
reflect population distributions and account
for each household’s probability of selection),
ratio adjustment to national population esti-
mates at the household level, and adjustment
for nonresponse. Because population esti-
mates may be unstable if cells have fewer
than 100 respondents, we combined such
small cells with other subgroups for our
analyses.21To obtain estimates of variability,
we used a Taylor Series estimation approach
with the SUDAAN software package.22We
performed χ2analyses to examine the distri-
bution of categorical variables among immi-
grants and US-born persons. We used t tests
to compare mean per capita health expendi-
tures among groups.
To obtain estimates of health expenditures
adjusted for potential covariates, we used the
Rand Health Insurance Experiment 2-part re-
gression model.23–25This model is used to an-
alyze heteroscedastic and highly skewed data
such as health care expenditures (many peo-
ple report no health care expenditures). The
model uses an initial multivariate logistic re-
gression to predict the probability of having
any expenditure. This probability is multiplied
by the predicted log-transformed expenditure
of any individual with nonzero expenditures
(as determined from a multivariate linear re-
gression model of individuals with nonzero
expenditures). For this 2-part model, we used
SUDAAN statistical software, which allows
adjustment for complex survey design.
Covariates in the 2-part model included
the following: age (analyzed as both a contin-
uous and a categorical variable), gender,
race/ethnicity, family income (dichotomized
as either <200% or ≥200% of the federal
poverty level [FPL]), education, insurance
status, self-reported health status, residence
in a metropolitan statistical area, and geo-
graphic region. In preliminary models, we
found that after adjustment for other covari-
ates, gender, education, geographic region,
and metropolitan statistical area were no
longer significant predictors of health care
expenditures, nor did they improve the
model fit. They were therefore excluded,
leaving the following covariates in the final
regression models to predict expenditures:
age (as a continuous variable), race/ethnicity,
insurance status, family income, and self-
reported health status. Additionally, we ex-
plored the possibility of interactions of the
covariates with immigrant status. We found
a significant interaction between immigrant
status and race/ethnicity, and therefore in-
cluded an interaction term in the multivariate
As in other studies,26,27we used smearing
factors to retransform the final estimates28,29
and calculated standard errors for predicted
expenditures, using bootstrapping with 2000
iterations.30We also conducted a stratified re-
gression analysis of health care expenditures
by insurance status and income, again con-
trolling for the other covariates in the model.
We opted to perform these stratified analyses
because income and insurance status are im-
portant predictors of health service use.
We also performed a subgroup analysis of
government payments (Medicare, Civilian
Health and Medical Program of the Uni-
formed Services of the United States
[CHAMPUS], Civilian Health and Medical
August 2005, Vol 95, No. 8 | American Journal of Public HealthMohanty et al. | Peer Reviewed | Research and Practice | 1433
RESEARCH AND PRACTICE
Program of the Veterans Administration
[CHAMPVA], Tricare, Medicaid, and other
public hospital/physician coverage) by using a
2-part multivariate regression model similar
to that described in this section.
Because children’s health care use differs
from that of adults and is of particular policy
interest,26,31,32we performed separate analy-
ses comparing immigrant children (n=276)
with US-born children (n=5657) younger
than 18 years. For children, we also used a
2-part model regression analysis similar to
that described in this section, controlling for
age, race/ethnicity (including a term captur-
ing the interaction of race/ethnicity with im-
migrant status), poverty level, insurance sta-
tus, and functional status. In our model for
children, we included 2 variables that have
been used as surrogates for a child’s func-
tional status20,26: (1) whether a child resists
illness well (reported by a parent) and
(2) whether a child performs age-appropriate
tasks (also reported by a parent).
In 1998, immigrant health care expendi-
tures were $39.5 billion (SE=$4.0 billion),
or 7.9% of the US total. This figure included
$25.0 billion (SE=$3.4 billion) in payments
made by private insurers on behalf of immi-
grants, $2.8 billion (SE=$0.4 billion) paid
directly by immigrants, and $11.7 billion
(SE=$1.7 billion) paid by government
sources. US-born individuals (90% of the
population) accounted for 93% of private
insurer expenditures and 92% of both gov-
ernment and out-of-pocket payments.
We found that immigrants differ from US-
born persons in demographics, unadjusted
per capita health expenditures, and adjusted
health expenditures. Demographic data are
presented in Table 1. Immigrants overall were
younger, although the immigrant population
contained a lower proportion of children than
did the US-born population. In addition, com-
pared with US-born persons, immigrants had
lower incomes and educational attainment
and lower self-reported health status, and
were more likely to live in the West, the
Northeast, and urban regions.
Unadjusted per capita total health care ex-
penditures were lower for immigrants than
TABLE 1—Demographic and Health Characteristics of US-Born Persons and of Immigrants
Residing in the United States: 1998
Family income as % of federal poverty level
Near-poor (100 to <125)
Low (125 to <200)
Middle (200 to <400)
Education (among adults)
Region of country
Residence in metropolitan statistical area
Note. NS=nonsignificant.Data are from the 1998 Medical Expenditure Panel Survey and the 1996–1997 National Health
aTotal US-born population=229 million.
bTotal immigrant population=25 million.
American Journal of Public Health | August 2005, Vol 95, No. 8 1434 | Research and Practice | Peer Reviewed | Mohanty et al.
RESEARCH AND PRACTICE
TABLE 2—Unadjusted Per Capita Health Care Expenditures of US-Born Persons and
Immigrants Residing in the United States: 1998.
Per Capita Expenditures,$
US-Born Persons (SE)Immigrants (SE)
Family income as % of federal poverty level
Education (adults only)***
Region of country*
Residing in metropolitan statistical area ***
Total sample,mean expenditures***2005 (50)1582 (149)
Note. Data are from the 1998 Medical Expenditure Panel Survey and the 1996–1997 National Health Interview Survey.
*P<.05; **P<.01; ***P<.001 (for comparison between immigrants and US born).
for the US born across all age groups (the
difference for those 65 years and older was
not statistically significant) (Table 2). For ex-
ample, per capita expenditures of immigrant
children younger than 12 years were 49%
lower than those of US-born children, and ex-
penditures of immigrant children aged 12 to
17 years were 76% lower than those of US-
born adolescents. The differences in expendi-
tures between immigrants and nonimmigrants
were substantially greater for men than for
women. Poorer immigrants and immigrants
with government insurance had lower expen-
ditures than did the poorer US born and the
US-born publicly insured.
In Figure 1, we present percentile distribu-
tions of total health care expenditures, com-
paring US-born persons and immigrants. Total
health care expenditures for both groups
were highly skewed. The median total expen-
diture for health care was $1563 for US-born
persons versus $1163 for immigrants (P<
.0001). For all deciles shown, health care ex-
penditures for US-born individuals were sig-
nificantly higher than those for immigrants. In
the lowest 3 deciles of health care expendi-
tures, immigrants had no reported expenses.
In the top decile, US-born individuals had ex-
penditures that were $1342 higher than
those for immigrants in 1998.
In our 2-part multivariate logistic regres-
sion model, immigrants had a lower probabil-
ity of expenditures and a lower probability of
expenditures for emergency care, office-based
visits, and prescription medications than US-
born persons (data not shown).
Adjusted expenditures were lower for all
immigrants than for all US-born persons
across all expenditure subgroups (Table 3).
Health care expenditures for immigrants av-
eraged $1139 per person in 1998, com-
pared with $2546 for US-born persons
(P<.0001). Immigrants also had lower ad-
justed expenditures for emergency care, of-
fice-based visits, outpatient visits, inpatient
visits, and prescription drugs. Our confirma-
tory analysis of charges rather than expendi-
tures found virtually identical trends (data
We also performed a multivariate analysis
of health care expenditures stratified by insur-
ance status and income. Per capita total ex-
penditures of insured immigrants (those with
any private or public insurance) were 52%
lower than those of insured US-born individu-
als; expenditures for uninsured immigrants
were 61% lower than those for the US-born
uninsured. In a subgroup analysis limited to
persons with public coverage, per capita ex-
penditures of publicly insured immigrants
were 44% lower than those of US-born per-
sons who were publicly insured ($2774 [SE=
$231] vs $4963 [SE=$189]; P<.0001). Ex-
penditures of higher-income immigrants
(those with incomes ≥200% of the FPL)
August 2005, Vol 95, No. 8 | American Journal of Public HealthMohanty et al. | Peer Reviewed | Research and Practice | 1435
RESEARCH AND PRACTICE
Note. Dollar figures are for median total health care expenditures within each decile.
FIGURE 1—Percentile distributions of total 1998 health care expenditures of US-born
persons and immigrants residing in the United States in 1998.
were 53% lower than those of higher-income
US-born persons; health care expenditures of
lower-income immigrants (those with incomes
<200% of the FPL) were 60% lower than
those of lower-income US-born individuals.
Similar patterns were seen in analyses of ex-
penditures for emergency care, office-based
visits, outpatient visits, inpatient visits, and
prescription drugs stratified by insurance and
Immigrant children were much more
likely than US-born children to be uninsured
(29% vs 9%, P<.0001) or publicly insured
(31% vs 20%, P<.0001). However, immi-
grant children’s rates of public coverage
were disproportionately low compared with
the same children’s poverty rates; 43% of
immigrant children lived in low-income fami-
lies, compared with 23% of US-born chil-
Results of the unadjusted and adjusted
models for children are shown in Table 3. Ex-
penditures for total health care, office-based
visits, outpatient visits, inpatient visits, and
prescription drugs were markedly lower for
immigrant children than for US-born children.
However, per capita emergency department
expenditures were more than 3 times higher
among immigrant children than among US-
We performed a stratified analysis by in-
surance status and income of children’s
health care expenditures. Health care expen-
ditures for insured immigrant children were
60% lower than those for insured US-born
children. Health care expenditures for unin-
sured immigrant children were 86% lower
than those for uninsured US-born children.
Expenditures among higher-income immi-
grant children were 53% lower than those
among higher-income US-born children. Ex-
penditures of immigrant children in lower-in-
come brackets were 84% lower than those of
lower-income US-born children.
We also estimated health care expenditures
among all US-born persons and immigrants
according to race/ethnicity. As shown in
Table 4, after multivariate adjustment, non-
Hispanic Whites had the highest per capita
expenditures, whereas Hispanics and Asians
had the lowest per capita expenditures.
Health care expenditures were similar for US-
born and immigrant Asians. In contrast, ad-
justed health expenditures for immigrant non-
Hispanic Whites, non-Hispanic Blacks, and
Hispanics were lower than those for US-born
individuals from these groups.
Immigrants have less access to health care
and less health care use than do US-born in-
dividuals, as reflected in their lower health
care expenditures. Studies have shown that
insurance coverage increases access to care
and thus utilization of care, as well as improv-
ing health outcomes.33–35In our study, we
found that per capita health care expendi-
tures for immigrants in 1998 were far lower
than expenditures for the US born. In addi-
tion, among adults and children enrolled in
publicly financed insurance programs, immi-
grants had lower per capita publicly-financed
health care expenditures than did the US
born. We also found grave disparities in ex-
penditures among most racial/ethnic groups,
particularly among immigrants who were
non-Hispanic White, non-Hispanic Black, or
When stratified by age, immigrants in
every age group but 65 years and older had
health care expenditures that were 30% to
75% lower than those for US-born persons.
Disparities among children were greatest, par-
ticularly among adolescents 12–17 years old.
Combined with our finding of higher per ca-
pita emergency department expenditures for
immigrant children, our data suggest that ac-
cess to routine and ongoing care may be es-
pecially problematic for immigrant children.
These findings are consistent with those of a
1999 study using NHIS data36that showed
foreign-born children were 5 times more
likely than US-born children to lack a usual
source of health care.
Ku and Matani37found that noncitizen chil-
dren were less likely than citizen children to
have made both ambulatory and emergency
department visits. Like Ku and Matani, we
found a significantly lower mean number of
emergency department visits among immi-
grant children than among US-born children
(data not shown); however, per capita emer-
gency department expenditures for immigrant
children were significantly higher because im-
migrant children’s costs per visit were much
higher. This finding suggests that immigrant
American Journal of Public Health | August 2005, Vol 95, No. 8 1436 | Research and Practice | Peer Reviewed | Mohanty et al.
RESEARCH AND PRACTICE
TABLE 4—Adjusted Per Capita Health
Care Expenditures Among US-Born
Persons and Immigrants of All Ages,
Per Capita Expenditures,$
1460 (198) 1324 (82)
Note. Data are from the 1998 Medical Expenditure
Panel Survey and the 1996–1997 National Health
aMean per capita expenditures were predicted by a
2-part model with adjustments for age,poverty level,
insurance status,and patient-reported health status.
***P<.001 (for comparison with US born).
TABLE 3—Unadjusted and Adjusted Mean Per Capita Health Care Expenditures for All Ages
and Subgroup Analysis for Children: 1998
Per Capita Expenditures,$
US Born (SE) Immigrant (SE)US Born (SE) Immigrant (SE)
Total health care
Note. Data are from the 1998 Medical Expenditure Panel Survey and the 1996–1997 National Health Interview Survey.
aFor all age groups,mean per capita expenditures were predicted by a 2-part model with adjustments for age,ethnicity,poverty
level,insurance status,patient-reported health status,and a term for the interaction of immigrant status and ethnicity.
bFor children,mean per capita expenditures were predicted by a 2-part model with adjustments for age,race/ethnicity,
poverty level,insurance status,parent-reported health status (whether a child resisted illness well and whether a child
performed age-appropriate social roles),and a term for the interaction of immigrant status and ethnicity.
*P<.05; **P<.01; ***P<.001 (for comparison with US born).
children may be sicker when they arrive at
the emergency department. The higher emer-
gency department expenditures we found for
immigrant children probably reflect poor ac-
cess to primary care (as evidenced by such
childrens’ low outpatient, office-based visit
Some of our findings may be explained by
the limits that the 1996 welfare reform legis-
lation38,39imposed on immigrants’ eligibility
for government health services. The Per-
sonal Responsibility and Work Opportunity
Reconciliation Act12and the Illegal Immigra-
tion Reform and Immigrant Responsibility
Act40substantially restricted recent immi-
grants’ eligibility for Medicaid and other
Before 1996, all legal permanent residents
and other legal immigrants had the same ac-
cess to public benefits, including Medicaid, as
did US citizens. However, welfare reform and
other policies established a 5-year ban on
Medicaid eligibility for nonrefugee immi-
grants entering the United States after Au-
gust 1996. The reform also stated that the
income of immigrants’ sponsors would be
counted in determining eligibility and that
sponsors could be held financially liable for
public benefits used by immigrants. These
policies created confusion about eligibility
and appeared to lead even eligible immi-
grants to believe that they should avoid pub-
lic programs. Even in states that have at-
tempted to continue public insurance for
immigrants, lack of awareness of eligibility
for these programs remains a problem.41
Our findings remained robust even after
adjustment for health insurance status, sug-
gesting that immigrants compared with the
US born, face additional unmeasured access
barriers, including cultural and linguistic bar-
riers.42–44As an example 1 study at an inner-
city clinic found that 1 in 9 immigrant par-
ents reported that they had not brought their
children in for care because they felt that the
medical staff did not understand Latino cul-
ture.45Additionally, among the 5–10 million
immigrants residing in the United States who
are undocumented, fear of deportation is a
Our finding of lower health care expendi-
tures among immigrants cannot be explained
by free care. The MEPS captures free care
(and bad debt) in public (but not private) in-
stitutions as expenditures; the MEPS captures
free care at any site as a charge. Our charge-
based analysis yielded results very similar to
those of our primary, expenditure-based anal-
ysis, indicating that adjustment of expenditure
data for free care at private institutions would
not change our results. This conclusion is also
supported by a recent study that found no re-
lationship between a state’s uncompensated
care burden and its percentage of noncitizen
immigrants.47The deficit of care among im-
migrants is probably not because of less need;
immigrants in our study had slightly worse
self-reported health than US-born persons.
Several limitations of this study should be
noted. First, because the 1998 MEPS, like
the 2000 US census,1did not ask about im-
migration or citizenship status, we could not
distinguish between naturalized citizens and
August 2005, Vol 95, No. 8 | American Journal of Public Health Mohanty et al. | Peer Reviewed | Research and Practice | 1437
RESEARCH AND PRACTICE
other immigrant groups. Thus, our immi-
grant category included many European-
born persons who resided in the United
States for decades, had already become US
citizens, and had fully assimilated into US
culture and the US economy and health care
system. Had we been able to exclude such
immigrants, we would probably have found
greater disparities. Similarly, we could not
specifically identify undocumented persons,
whom we suspect have the lowest health
Our study also could not capture health
care expenditures outside the United States,
where some immigrants may travel to obtain
care or prescription drugs. For example, im-
migrants near the Mexican border may obtain
medications from pharmacies in Mexico.
However, these omitted out-of-country expen-
ditures could not be viewed as a burden on
the US health care system. MEPS also omits
expenditures for medical care received by
institutionalized persons (including nursing
home residents) and for nonprescription
drugs. Studies have consistently found that
racial/ethnic minority populations reside
in nursing homes less often than do non-
Our findings show that widely held as-
sumptions that immigrants are consuming
large amounts of scarce health care resources
are invalid; these findings support calls to re-
peal legislation proposed on the basis of such
assumptions. The low expenditures of pub-
licly insured immigrants also suggest that pol-
icy efforts to terminate immigrants’ coverage
would result in little savings. In addition,
lower health care expenditures by immigrants
suggest important disparities in health care
use, especially for children. Immigrant chil-
dren will grow up to become a major seg-
ment of the US workforce in the coming
years. Ensuring access to health services
needed for proper growth and development
should be a national priority. Policies that
may improve immigrants’ access to care in-
clude providing interpreter services, ending
restrictions on Medicaid and State Children’s
Health Insurance Program eligibility, improv-
ing employer-provided coverage for immi-
grant workers, and implementing universal
national health insurance.49Our study lends
support to these and other initiatives aimed at
reducing and ultimately eliminating dispari-
ties in access to and use of health services.
About the Authors
Sarita A. Mohanty is with the Department of Medicine, Di-
vision of Geriatric and General Internal Medicine, Univer-
sity of Southern California, Los Angeles. Steffie Woolhan-
dler, David U. Himmelstein, and David H. Bor are with
the Department of Medicine, Cambridge Health Alliance
and Harvard Medical School, Cambridge, Mass. Susmita
Pati is with The Children’s Hospital of Philadelphia and
the Leonard Davis Institute of Health Economics, Univer-
sity of Pennsylvania, Philadelphia. Olveen Carrasquillo is
with the Division of General Medicine, Columbia Univer-
sity College of Physicians and Surgeons, New York, NY.
Requests for reprints should be sent to Sarita A. Mo-
hanty, MD, MPH, Department of Medicine, Division of
Geriatric and General Internal Medicine, University of
Southern California, 2020 Zonal Ave, IRD 627, Los
Angeles, CA 90033 (email: firstname.lastname@example.org).
This article was accepted August 6, 2004.
S.A. Mohanty originated the study, supervised all as-
pects of it, and completed the analyses. S. Woolhandler,
D.U. Himmelstein, S. Pati, and O. Carrasquillo helped
with conception of the study, interpretation of the find-
ings, and writing the article. D.H. Bor assisted with in-
terpretation of findings and editing the article. All au-
thors contributed to study conception and design,
acquisition of data, analysis and interpretation, and
writing the article.
S.A. Mohanty’s work was supported by an Institutional
Health Resources and Services Administration research
award, US Department of Health and Human Services
(grant 5 D08 HP 50018).
Human Participant Protection
This study received institutional review board exemp-
tion from the University of Southern California.
1. Schmidley AD. Profile of the Foreign-Born Popula-
tion in the United States: 2000. Washington, DC: US
Census Bureau; 2001. Current Population Reports, se-
nomic, Demographic, and Fiscal Effects of Immigration.
Washington, DC: National Academy Press; 1997.
Smith JP, Edmonston B. The New Americans: Eco-
security with billions. New York Times. April 5,
2005;sect. A:1 and sect. C:6.
Porter E. Illegal immigrants are bolstering social
insurance coverage of immigrants living in the
United States: differences by citizenship status and
country of origin. Am J Public Health. 2000;90(6):
Carrasquillo O, Carrasquillo AI, Shea S. Health
Pays? Austin: House Research Organization, Texas
House of Representatives; October 19, 2001. Report
Health Care for Undocumented Immigrants: Who
report by the Federation for American Immigration Re-
form, June 2004. Available at: http://www.fairus.org/
news/NewsPrint.cfm?ID=2442&c=55. Accessed May
The costs of illegal immigration to Arizonans: a
grant care. October 21, 2002. Available at: http://www.
Accessed March 6, 2003.
Hawryluk M. States might get help with immi-
own dispossession? July 31, 2001. Available at: http://
cessed March 6, 2003.
Levin M. Must Texas taxpayers subsidize their
Review, April 29, 2003. Available at: www.austinreview.
com. Accessed May 15, 2003.
Allen C. Immigration and the budget. The Austin
10. Without Coverage: Immigration’s Impact of the Size
and Growth of the Population Lacking Health Insurance.
Washington, DC: Center for Immigration Studies; July
lic Services. Verification and Reporting. California Ballot
Pamphlet: General Election. Sacramento: Secretary of
State; November 8, 1994:54–55.
Proposition 187: Illegal Aliens. Ineligibility for Pub-
12. Personal Responsibility and Work Opportunity
Reconciliation Act, Pub L 104-193, 110 Stat 2105,
August 22, 1996. Available at: http://wdr.doleta.gov/
readroom/legislation/pdf/104-193.pdf. Accessed May
13. Demographic shifts divide races: no consensus on
the census. The Pew Research Center for the People and
the Press, May 13, 2001. Available at: http://people-
March 15, 2003.
14. Cohen JW, Monheit AC, Beauregard KM, et al.
The Medical Expenditure Panel Survey: a national
health information resource. Inquiry. 1996;33(4):
15. MEPS HC-028: 1998 full year consolidated data
file. Agency for Healthcare Research and Quality, De-
cember 2001. Available at: http://www.meps.ahrq.gov/
Pubdoc/HC028/H28DOC.pdf. Accessed April 2003.
16. Monheit AC, Wilson R, Arnett RH. Informing
American Health Care Policy: The Dynamics of Medical
Expenditure and Insurance Surveys, 1977–1996. San
Francisco, Calif: Jossey-Bass Publishers; 1999.
ing medical expenditure estimates from the MEPS and
the NHA, 1996. Health Care Financ Rev. 2001;23(1):
Selden TM, Levit KR, Cohen JW, et al. Reconcil-
18. Canady D. Hospitals feeling strain from illegal im-
migrants. New York Times. August 25, 2002;sect 1:16.
19. Public use file main data results. April 2002.
Agency for Healthcare Research and Quality, Rockville,
Md. Available at: http://www.meps.ahrq.gov/Puf/
PufDetail.asp?ID=69. Accessed April 4, 2003.
20. Newacheck PW, Inkelas M, Kim SE. Health ser-
vices use and health care expenditures for children
with disabilities. Pediatrics. 2004;114(1):79–85.
21. Cochran WG. Sampling Techniques. 3d ed. New
York, NY: John Wiley; 1977.
22. Shah BV, Barnwell BG, Bieler GS. SUDAAN
User’s Manual. Research Triangle Park, NC: Research
Triangle Institute; 1997.
American Journal of Public Health | August 2005, Vol 95, No. 8 1438 | Research and Practice | Peer Reviewed | Mohanty et al. Download full-text
RESEARCH AND PRACTICE
23. Manning WG, Bailit HL, Benjamin B, Newhouse JP.
The demand for dental care: evidence from a random-
ized trial in health insurance. J Am Dent Assoc. 1985;
24. Brook RH, Ware JE Jr, Rogers WH, et al. Does
free care improve adults’ health? Results from a ran-
domized controlled trial. N Engl J Med. 1983;309(23):
25. Duan N, Manning W, Morris C, Newhouse J. A
comparison of alternative models for the demand for
medical care. J Bus Econ Stat. 1983;1:115–126.
26. Pati S, Shea S, Rabinowitz D, Carrasquillo O. Does
gatekeeping control costs for privately insured chil-
dren? Findings from the 1996 Medical Expenditure
Panel Survey. Pediatrics. 2003;111(3):456–460.
27. Chen AY, Chang RK. Factors associated with pre-
scription drug expenditures among children: an analy-
sis of the Medical Expenditure Panel Survey. Pediatrics.
28. Duan N. Smearing estimate: a nonparametric re-
transformation method. JAMA. 1983;78:605–610.
29. Manning WG. The logged dependent variable,
heteroscedasticity, and the retransformation problem.
J Health Econ. 1998;17(3):283–295.
30. Mooney CZ, Duval R. Bootstrapping: A Nonpara-
metric Approach to Statistical Inference. Newbury Park,
Calif: Sage Publications; 1993.
31. Agency for Healthcare Research and Quality.
HCUP Fact Book No. 4, Care of Children and Adoles-
cents in US Hospitals. Available at: http://www.ahrq.
gov/data/hcup/factbk4/factbk4.htm. Accessed April 8,
32. Pati S, Shea S, Rabinowitz D, Carrasquillo O.
Health expenditures among privately insured adults
enrolled in managed care gatekeeping vs indemnity
plans. Am J Public Health. 2005;95:286–291.
33. Kaiser Family Foundation. Immigrants’ health
care: coverage and access. August 2000. Available at:
http://www.kff.org. Accessed November 4, 2002.
34. Eisert S, Gabow P. Effect of Child Health Insur-
ance Plan enrollment on the utilization of health care
services by children using a public safety net system.
35. Salganicoff A, Wyn R. Access to care for low-
income women: the impact of Medicaid. J Health Care
Poor Underserved. 1999;10(4):453–467.
36. Brown ER, Wyn R, Yu H, Valenzuela A, Dong L.
The health and nutritional status of analyses of the
Hispanic Health and Nutrition Examination Survey. In:
Hernandez DJ, ed. Children of Immigrants: Health, Ad-
justment, and Public Assistance. Washington, DC: Na-
tional Academy Press; 1999:126–186.
37. Ku L, Matani S. Left out: immigrants’ access to
health care and insurance. Health Aff (Millwood). 2001;
38. Office of the Assistant Secretary for Planning and
Evaluation, Department of Health and Human Ser-
vices. Summary of immigrant eligibility restrictions
under current law, October 2002. Available at: http://
Accessed November 8, 2002.
39. Zimmerman W, Tumlin K. Patchwork Policies:
State Assistance for Immigrants Under Welfare Reform.
Washington, DC: The Urban Institute; 1999. Assessing
the New Federalism Occasional Paper, report 24.
40. Illegal Immigration Reform and Immigrant Re-
sponsibility Act, Pub L 104-208, 110 Stat 3009, Sep-
tember 30, 1996. Available at: http://frwebgate.ac-
public_laws&docid=f:publ208.104.pdf. Accessed May
41. Massachusetts Immigrant and Refugee Advocacy
Coalition. Unequal access: a report on barriers children
in low-income immigrant families face in accessing
food stamps and health insurance. 2000. Available at:
www.miracoalition.org. Accessed March 6, 2002.
42. The Commonwealth Fund. Insuring the children
of New York City’s low-income families: focus group
findings on barriers to enrollment in Medicaid and
Child Health Plus. December 1998. Available at:
children_nyc_305.asp. Accessed April 10, 2002.
43. Woloshin S, Bickell NA, Schwartz LM, Gany F,
Welch HG. Language barriers in medicine in the
United States. JAMA. 1995;273(9):724–728.
44. Jacobs EA, Lauderdale DS, Meltzer D, Shorey JM,
Levinson W, Thisted RA. Impact of interpreter services
on delivery of health care to limited-English-proficient
patients. J Gen Intern Med. 2001;16(7):468–474.
45. Flores G, Abreu M, Olivar MA, Kastner B. Access
barriers to health care for Latino children. Arch Pediatr
Adolesc Med. 1998;152(11):1119–1125.
46. Asch S, Leake B, Gelberg L. Does fear of immi-
gration authorities deter tuberculosis patients from
seeking care? West J Med. 1994;161(4):373–376.
47. Castel LD, Timbie JW, Sendersky V, Curtis LH,
Feather KA, Schulman KA. Toward estimating the im-
pact of changes in immigrants’ insurance eligibility on
hospital expenditures for uncompensated care. BMC
Health Serv Res. 2003;3(1):1.
48. Dey AN. Characteristics of elderly home health
care users: data from the 1994 National Home and
Hospice Care Survey. Adv Data. 1996(279):1–12.
49. Schur CL, Feldman J. Running in Place: Character-
istics, Immigrant Status, and Family Structure Keep His-
panics Uninsured. Bethesda, Md: Project HOPE Center
for Health Affairs; 2001.
of childhood death and disability extends
well beyond the individual child to affect
all of us. This book empowers readers by
providing clear information about envi-
ronmental threats and what we can do to
The six chapters include Infectious
Diseases in the Environment; Injuries and
Child Health; The Legacy of Lead;
Environmental Chemicals and Pests;
Childhood Asthma; and Reducing
Environmental Health Risks. An
Appendix of activities to do with children
Pediatricians, child health care practi-
tioners and parents will find this book an
he health of our children is a critical
issue facing our society today. The toll
2000 ❚ 149 pages ❚ softcover
$13.50 APHA Members
plus shipping and handling
By Dona Schneider and
American Public Health Association