Journal of Gerontological Nursing

Public Policy 

Policy Implications of a Literature Review of Cardiovascular Disease in Uninsured Immigrant Older Adults

Tina R. Sadarangani, MSN, ANP-BC, GNP-BC

Abstract

The number of older adults emigrating to the United States is expected to quadruple by 2050. The health of immigrant older adults is complicated by the limited options for low-cost health insurance available to this population. Welfare reform has limited new immigrants’ access to public assistance programs, such as Medicaid; and low-cost private insurance options rarely exist for individuals older than 65, even with the passage of the Patient Protection and Affordable Care Act (PPACA). Uninsured immigrant older adults have been found to forgo preventive care due to cost and are among the leading users of emergency departments for preventable complications of chronic disease, primarily cardiovascular disease (CVD). A review of the literature found that insurance coverage has a significant impact on CVD risk among immigrant older adults. The current article discusses the implications of welfare reform initiatives and the shortcomings of the PPACA in addressing the health care needs of immigrant older adults. [Journal of Gerontological Nursing, 41(6), 14–20.]

Ms. Sadarangani is Doctoral Student, New York University College of Nursing, New York, New York.

The author has disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Tina R. Sadarangani, MSN, ANP-BC, GNP-BC, Doctoral Student, New York University College of Nursing, 433 First Avenue, 6th Floor, New York, NY 10010; e-mail: trs233@nyu.edu.

Posted Online: April 17, 2015

Abstract

The number of older adults emigrating to the United States is expected to quadruple by 2050. The health of immigrant older adults is complicated by the limited options for low-cost health insurance available to this population. Welfare reform has limited new immigrants’ access to public assistance programs, such as Medicaid; and low-cost private insurance options rarely exist for individuals older than 65, even with the passage of the Patient Protection and Affordable Care Act (PPACA). Uninsured immigrant older adults have been found to forgo preventive care due to cost and are among the leading users of emergency departments for preventable complications of chronic disease, primarily cardiovascular disease (CVD). A review of the literature found that insurance coverage has a significant impact on CVD risk among immigrant older adults. The current article discusses the implications of welfare reform initiatives and the shortcomings of the PPACA in addressing the health care needs of immigrant older adults. [Journal of Gerontological Nursing, 41(6), 14–20.]

Ms. Sadarangani is Doctoral Student, New York University College of Nursing, New York, New York.

The author has disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Tina R. Sadarangani, MSN, ANP-BC, GNP-BC, Doctoral Student, New York University College of Nursing, 433 First Avenue, 6th Floor, New York, NY 10010; e-mail: trs233@nyu.edu.

Posted Online: April 17, 2015

Immigrant older adults are reportedly among the most marginalized individuals in America (Brown, 2009). The population of immigrant older adults arriving in the United States, who are known as “newcomers” (Treas, 2008, p. 40), doubled in size between 1990 and 2010 and is projected to increase by more than three-fold, to approximately 16 million by 2050 (Batalova, 2012). Newcomers are especially vulnerable to negative health outcomes (Treas, 2008). The natural stressors of aging, combined with the challenges of resettlement, predispose these immigrant older adults to poor health over time.

Compared to younger cohorts, immigrant older adults describe greater difficulty adapting to their new environment (Shibusawa & Mui, 2010). On average, newcomers in the United States are between ages 60 and 79, settle in ethnic enclaves, and live in households with their adult children or other family members (Gorospe, 2005). The overwhelming majority of newcomers enter the United States legally as documented aliens (Reyes & Hardy, 2015). However, limited English proficiency, social isolation, financial instability, and poor physical health status are all significant barriers to healthy aging for these older adults (Shibusawa & Mui, 2010; Treas, 2008). Moreover, conditions in sending countries, including poor working and living environments, predispose immigrant individuals to poor health in older age (Gorospe, 2005).

Care of immigrant older adults, therefore, presents a formidable public health challenge. However, these challenges are compounded by strict eligibility rules following the enactment of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA), which limit newcomers’ access to Medicaid and other public assistance programs (Nam, 2008, 2012). Immigrant individuals, including older adults, who have arrived in the United States since the passage of PRWORA have been subjected to a 5-year waiting period for Medicaid in most states, which will remain unchanged despite the passage of the Patient Protection and Affordable Care Act (PPACA) (Choi, 2012; Nam, 2008, 2012). As of 2002, 55.8% of uninsured adults older than 65 in the United States were immigrants (United States Census Bureau, 2002). As the aging population becomes increasingly diverse and health care expenditures continue to rise, health outcomes, and the policies that may be adversely affecting them, should be reconsidered by lawmakers. Based on the results of an integrative review using Whittemore and Knafl’s (2005) framework on the cardiovascular health of immigrant older adults, the current article explores the integral role of health insurance in improving the cardiovascular health of these individuals, and the confluence of sociopolitical factors that underpin this association.

Insurance Coverage and Cardiovascular Disease

Lack of health coverage has been identified as a key factor that sustains health inequities among immigrant older adults (Choi, 2012; DuBard & Massing, 2007; Gorospe, 2005; Kaushal & Kaestner, 2005; Markides & Eschbach, 2005; Nam, 2008; Reyes & Hardy, 2014; Shibusawa & Mui, 2010; Shin, Song, Kim, & Probst, 2005; Sohn & Harada, 2004). Leaving newcomers without affordable access to preventive services is particularly problematic within the context of cardiovascular disease (CVD), which remains the number one cause of death worldwide (World Health Organization, 2015). Complications of CVD are the leading cause of emergency department (ED) visits among uninsured immigrant older adults (DuBard & Massing, 2007). Broadly speaking, uninsured late middle-age and older adults in the United States are less likely to receive care for major CVD risk factors, including diabetes and hypertension, and experience higher rates of mortality than those with insurance (Brooks et al., 2010). Uninsured individuals commonly defer treatment due to the high cost of provider visits, clinical and laboratory tests, and medications. These individuals are less likely to seek care, undergo routine examinations, be aware of their diagnoses, and receive treatment, especially for asymptomatic conditions, such as hypertension (Brooks et al., 2010).

A study by DuBard and Massing (2007) observed the potentially undue consequences of leaving newcomers uninsured. The authors found that newly arrived immigrant older adults were second only to pregnant women in their use of Emergency Medicaid. Emergency Medicaid refers to state-funded coverage provided to individuals, regardless of immigration status, for the treatment of acute, life-threatening medical events; it is estimated to cost taxpayers $2 billion annually (Galewitz, 2013). Immigrant older adults, with no form of alternate health coverage, primarily presented to EDs with potentially preventable complications of CVD, including stroke and myocardial infarction (DuBard & Massing, 2007). The nature of these visits illustrates an unmet need for treatment and prevention at the primary care level that may be a costly consequence of inadequate health coverage. However, despite the growing number of immigrant older adults and the rise in preventable complications of CVD in this population, the political, economic, and health implications of leaving immigrant older adults without options for affordable insurance coverage are rarely discussed in aggregate.

Literature Review

Since the passage of PRWORA, relatively little research has been conducted on the association between health insurance coverage and the prevalence, awareness, treatment, and control of CVD risk factors in immigrant older adults. PubMed (Medicine), CINAHL (Nursing and Allied Health), AgeLine (Gerontology), SocINDEX (Sociology), Sociological Abstracts (Sociology), and Web of Science (Various) were individually searched using a combination of the following index terms: aging, elderly, older, gerontology, immigra*, emigra*, health insurance, health services accessibility, Medicaid, or medically uninsured persons. Although more than 2,900 titles and abstracts were screened for the current review, only 11 articles (Afable-Munsuz, Mayeda, Pérez-Stable, & Haan, 2013; Balasubramanyam, Rao, Misra, Sekhar, & Ballantyne, 2008; Bersamin, Stafford, & Winkleby, 2009; Dallo, Wilson, & Stimpson, 2009; Eamranond et al., 2009; Sadowski, Devlin, & Hussain, 2012; Stoddard, He, Vijayaraghavan, & Schillinger, 2010; Ursua et al., 2014; Wu, Hsieh, Wang, Yao, & Oakley, 2011; Wu, Wang, & Chung, 2012; Zallman et al., 2013), which all used cross-sectional data, were topical and satisfied the inclusion criteria (i.e., included insurance coverage as an independent variable, covariate, or major theme; identified the outcome of interest as being one or more cardiometabolic risk factors; and included immigrant adults older than 65 in their analysis) (Figure).

Flow chart of search results.

Figure.

Flow chart of search results.

Comparison across the studies was limited because clinical guidelines used to determine the presence or absence of disease often diverged from one another. However, lack of insurance coverage was associated with disproportionately high rates of CVD risk factors and strikingly low rates of treatment, control, and awareness across samples containing immigrant older adults. Overall, immigrant older adults were significantly less likely to have health insurance coverage than their native born counterparts. Stoddard et al. (2010) found that within their sample, 54% of Mexican immigrants in the United States were uninsured, compared to 15% of Hispanic individuals born in the United States and only 4% of non-Hispanic White individuals (p < 0.05).

Prevalence rates for smoking, hypertension, diabetes, high cholesterol, and obesity were among the most consistently reported risk factors for CVD in these studies. The prevalence of diabetes ranged from 10% to 28.8%, thereby exceeding the national rate of 9.3% (Centers for Disease Control and Prevention [CDC], 2014). Rates of diabetes control were worse among immigrant populations, and clinical measures exceeded recommendations put forth by the American Diabetes Association (2014) for optimal diabetes management. Fasting blood glucose estimates ranged from 154.4 mg/dL in individuals with diagnosed diabetes to as high as 193.3 mg/dL among undiagnosed immigrant individuals (Eamranond et al., 2008; Stoddard et al., 2010). Reported values for glycated hemoglobin averaged 7.7% in undiagnosed immigrant individuals (Stoddard et al., 2010).

The prevalence of hyperlipidemia among samples containing immigrant older adults was exponentially higher than that of the overall population in the United States (CDC, 2014). Total cholesterol levels exceeded 200 mg/dL in 57.5% of Wu et al.’s (2011) sample of Asian immigrants. For Filipino immigrants, in particular, prevalence of hypercholesterolemia varied between studies, ranging from 31% in the study by Ursua et al. (2014) to 68.4% in the study by Wu et al. (2011). Eamranond et al. (2009) found that 53.7% of Hispanic adults failed to achieve acceptable low-density lipoprotein levels, and this was the case for approximately 65% of Asian Indian immigrants (Wu et al., 2011). Further, uninsured immigrant individuals were twice as likely as insured immigrant individuals, and four times as likely as insured U.S.-born adults, to have undiagnosed hypercholesterolemia (Zallman et al., 2013).

Immigrant older adults were also likely to have multiple comorbid conditions and generally had more than one risk factor for CVD. In one study, approximately 63% of adults with diabetes also had elevated blood pressure (Dallo et al., 2009). In a large nationally representative sample, approximately one in four Mexican American men and women with hypertension also had diabetes and were obese (Bersamin et al., 2009).

Among immigrant older adults, insurance also had strong implications on awareness, treatment, and control of the diseases that heighten cardiovascular risk (Bersamin et al., 2009; Eamranond et al., 2009; Ursua et al., 2014; Zallman et al., 2013). In general, foreign-born individuals were more likely to have poorly controlled elements of CVD than native-born adults (Bersamin et al., 2009; Ursua et al., 2014; Zallman et al., 2013). The majority of studies that addressed health awareness suggested that uninsured immigrant individuals were less knowledgeable about their own health and more likely to have undiagnosed health issues than those who had health insurance. Immigrant individuals demonstrated lower levels of basic knowledge related to CVD and were more likely to have undiagnosed conditions, even when questioned using validated culturally tailored surveys (Balasubramanyam et al., 2008). Mexican immigrants were more than twice as likely to be unaware that they had diabetes than U.S.-born Hispanic individuals (p < 0.05) (Stoddard et al., 2012). Asian Indian immigrants reportedly failed to correctly identify one half of the 18 risk factors for CVD (Balasubramanyam et al., 2008). This finding is especially surprising in light of the fact that Asian Indian individuals in the United States, 35% of whom have a bachelor’s degree, have some of the highest levels of educational attainment among all immigrant groups (Bureau of Labor Statistics, 2011).

Strong associations were found between having insurance coverage and improved control of cardiovascular risk factors in nationally representative samples of older adults. Lack of insurance prevented participants from accessing necessary care (Bersamin et al., 2009; Eamranond et al., 2009; Zallman et al., 2013). Moreover, it was not simply the lack of insurance, but the type of insurance (i.e., public versus private) that enhanced treatment seeking and self-management among immigrant older adults. Medicaid coverage, in particular, was highly predictive of treatment and self-management for CVD risk factors (Bersamin, 2009; Sadowski et al., 2012). Zallman et al. (2013) and Bersamin et al. (2009) found that adults receiving Medicaid were significantly more likely to be aware that they had hypertension than those who were uninsured.

Discussion and Analysis

Immigrant older adults have disproportionately high rates of CVD risk factors and simultaneously low rates of treatment, awareness, and control over these factors; they are also less likely to have health coverage than non-immigrant older adults. The review of the literature exposed the essential role of insurance coverage in the management of CVD risk factors among immigrant older adults. Although the cross-sectional data in these studies limit causal inference, higher CVD risk was associated with lack of health insurance coverage. These findings give credence to DuBard and Massing’s (2007) claim that uninsured immigrant older adults are highly likely to seek emergency services for complications of CVD.

The important role of insurance coverage in facilitating health care access among middle-age and older immigrant adults is also consistent with more general surveys of immigrant populations that address the relationship between insurance and health. For example, a community-based survey of Korean older adults in Los Angeles, California found that insurance coverage was more closely associated with health care use and seeking treatment than acculturation or language barriers (Shin et al., 2005). Shibusawa and Mui (2012) examined data from Asian American Elders in New York City, focusing specifically on data collected among Asian Indian participants. Among these immigrant older adults, less than one in four were insured and more than 80% self-reported delaying physician visits because of concerns over cost (Shibusawa & Mui, 2012).

Insurance barriers, therefore, create insufficient access to care, leaving immigrant older adults unable to retrieve basic preventive care services that are essential in the prevention of CVD (Bowen & Nelson, 2002). It is clear that the stressors that accompany resettlement often have long-lasting detrimental effects on the physical and mental health of immigrant individuals (Hilfinger Messias, McEwen, & Boyle, 2015). These stressors are particularly impactful in middle age, a precarious point in the health trajectories of adults, when the need for many routine health screenings (e.g., laboratory testing for cardiovascular risk factors) begins (Reyes & Hardy, 2015). Middle age also happens to be the time at which many immigrant adults make the decision to resettle abroad. It is well established that gaps in insurance coverage in later middle age can delay the diagnosis and treatment of chronic conditions, and in the current review, samples of immigrant older adults also tended to have worse health than their native-born counterparts. Keeping in mind that options such as private insurance and employer-sponsored coverage are often out-of-reach to pre-retiree and retiree populations, policy plays a key role in making insurance more widely available to immigrants, thus improving their overall health.

Immigrant older adults’ access to affordable health insurance is most fundamentally restricted by legislation that limits public assistance available to non-citizens. These limitations include the 5-year moratorium on government aid, requirements for employment, and employment history required for Medicare (Reyes & Hardy, 2015). These policies were underpinned by the government’s desire to deter immigration at certain points in history (Hilfinger Messias et al., 2015). Moreover, the health care system in the United States is marred by complex bureaucracy that makes medical care inaccessible to individuals who are not financially stable and experience limited English proficiency.

Yet, despite limitations on welfare benefits to immigrant individuals, the United States, unlike other nations, such as Canada or Australia, does not impose age restrictions on immigrant individuals seeking entry into the United States. In fact, policies that support family reunification inadvertently encourage naturalized citizens to bring their aging parents to the United States. Moreover, immigration law has a low threshold to ensure financial self-sufficiency and requires that immigration sponsors earn just 125% of the poverty line. Therefore, the limited availability of affordable health insurance options to immigrant older adults reflects the intersectionality of aging, poverty, immigration, and health care (Reyes & Hardy, 2015).

Implications

Lack of insurance may be a more significant barrier to health care access for immigrant older adults who have spent less of their lives in the United States compared to those who lived in the United States longer. Across studies, a large share of immigrant individuals had been in the United States less than 15 years, and according to Zallman et al. (2013), approximately 60% had been in the United States for 5 years or less. Although some studies conclude that greater proportion of life in the United States is associated with worse health outcomes, in Eamranond et al.’s (2009) study, length of stay in the United States was correlated with improved control over risk factors due to greater access to health care. The “healthy immigrant effect,” a phenomenon in which immigrant populations are believed to be healthier than native-born individuals, has been studied to diminish in older adults as soon as 2 years after their arrival in Western countries (Newbold, 2009, p. 330). This effect suggests that although those who have been in the country longer may continue to benefit from lifestyle changes to reduce morbidity and mortality, recently arrived immigrant individuals require greater access to health care earlier in the resettlement period to reduce long-term cardiovascular risk.

The high rate of uninsured immigrant individuals in these studies, especially among those recently arrived, is largely a consequence of PRWORA, as options for health coverage, beyond Medicaid, are largely unavailable for newcomers. Medicare Part A is only available to those who have worked in Medicare-covered employment, and few private insurance companies offer affordable policies for individuals older than 65 (Choi, 2012; Markides & Eschbach, 2005; Nam, 2008). The PPACA, which does not address the needs of individuals older than 65 who do not qualify for Medicare, does little to improve the welfare of immigrant older adults. Under this legislation, 5-year Medicaid waiting periods for immigrant individuals in most states remain. Immigrant older adults are unlikely to face penalties for not having insurance because their incomes likely fall below the limits for filing tax returns and are eligible for hardship exemptions; therefore, they are likely to remain without insurance (Centers for Medicare & Medicaid Services, 2014).

Insurance helps defray the high cost of health care in the United States and enables greater access to care and treatment, especially in low-income populations. Conversely, as the current review illustrates, lack of insurance creates additional treatment barriers in immigrant populations whose access to care is already limited by income, language, transportation, and/or lack of health awareness, and whose needs are greater due to advancing age. In turn, delayed or inadequate treatment increases the likelihood of complications, especially from CVD, and necessitates more costly emergent care as disease progresses (DeLia, 2006; DuBard & Massing, 2007). Acute hospitalizations resulting from complications of CVD are more costly for older patients, and ultimately reimbursed through taxpayer endowed Emergency Medicaid programs and state charity care programs, which face chronic funding shortfalls (DeLia, 2006). Legislative efforts to restrict public assistance to new immigrant individuals have inadvertently fostered poor health outcomes in these individuals, many of which are related to CVD and may be preventable with greater access to primary care. This legislation also shifts unnecessary costs to state governments and the local hospitals that treat these populations, creating an economically inefficient system of health care delivery. All the while, disease progression decreases quality of life for older adults.

Recommendations

Andersen and Newman (1973), in their model of health care use, suggested that health care resources be devoted to the most mutable elements of disease. Insurance improves access to preventive care and has been studied to be a key modifiable risk factor associated with diagnosis and control of hypertension and hyperlipidemia (Zallman et al., 2013). Therefore, expanding low-cost or government insurance plans to immigrant older adults is an important consideration in preventing complications of CVD, especially for those who are newcomers. Mobilizing resources at community and national levels, such as through Medicaid policy change, may be an appropriate means by which to bring about large-scale improvements in health outcomes among immigrant older adults.

The American Nurses Association has casted health care as a fundamental human right that should be available to all residents of the United States (McGuire, 2015). Nurses must, at the very least, be taught the sociopolitical implications of leaving immigrant older adults without access to affordable health coverage. Informed nurses will then be able to advocate for social justice and policy changes that empower this population and improve access to care (McGuire, 2015). Political advocacy is essential to promoting the health, safety, and integrity of marginalized populations who the nursing profession has a history of serving. To engage in advocacy, nurses must first understand the unique motivations of immigrant older adults and, in turn, educate the public on the needs of this vulnerable population. Nursing’s power to restructure the conversation on public assistance to immigrant older adults is especially critical at a time when lawmakers are engaged in active debates on both health care and immigration policies.

Conclusion

The number of immigrant older adults in the United States continues to grow, yet few health care resources are being directed toward this population, even in the wake of historic changes to domestic health care policy. Immigrant older adults’ disproportionate use of emergency care for complications of CVD should not be surprising given the high prevalence of cardiovascular risk factors among samples of immigrant older adults in the current review and low rates of insurance coverage. Therefore, expanding health insurance to immigrant older adults has the potential to improve rates of treatment, control, and awareness for CVD. However, further research, focusing exclusively on immigrant older adults who face higher levels of risk and greater access barriers, is needed to understand the role of insurance in improving disease outcomes. Future research should view insurance as a primary predictor of health outcomes in quantitative models and explicitly focus on older populations and their cardiovascular health. Moreover, further qualitative inquiry may better elucidate how expanded resources align with immigrant health practices, and shed light on the dynamic interplay of social forces that give rise to the immigrant experience. Ideal studies would assess newcomers’ health over time, starting from their initial entry into the United States, and assess for association between insurance status and long-term health outcomes.

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