Dataspeak -- June 2002 -- Transcript

"The Health of Immigrant Populations: Coverage, Access and Outcomes"
June 13, 2002

Welcome and Overview
Mary Overpeck, DrPH
Maternal and Child Health Bureau

Logistics
Beth Zimmerman, MHS
MCH Information Resource Center

>> MARY OVERPECK: Good afternoon. This is Dr. Mary Overpeck of the Maternal and Child Health Bureau and on their behalf I would like to welcome all of you to today's Dataspeak Internet audio conference. The Dataspeak series is sponsored by the Maternal and Child Health Bureau Office of Data and Information Management and is coordinated by the Bureau's MCH Information Resource Center. Dataspeak is a program that focuses on research, data, and methodological issues in maternal and child health.

We are very pleased that the Dataspeak audio conferences have been made available through the Internet as well as through the traditional conference call format. I would like to extend a special thanks to the Center for the Advancement of Distance Education at the University of Illinois in Chicago for developing and supporting the Internet component of this Dataspeak audio conference. I would also like to thank the Centers for Disease Control and Prevention for providing the audio conference bridge for our telephone conference call participants. The discussions do not necessarily represent views of the sponsoring agencies.

Today's Dataspeak, which is the final program in our 2002 spring Dataspeak series, addresses the health of immigrants in the United States, a group which in 2000 made up approximately 11% of our nation's population.

We are fortunate to have Dr. Julie Hudman of the Kaiser Commission on Medicaid and the Uninsured, and Dr. Stella Yu of the Maternal and Child Health Bureau as presenters for today's program. Dr. Hudman will use data from a number of sources. Dr. Yu will discuss recent studies on the health and well-being of immigrant children based on representative data based on the school based study of health behavior in school aged children. It is a part of a larger research project involving about 30 countries and sponsored by the Maternal and Child Health Bureau and the National Institute of Child Health. It is now my pleasure to introduce Beth Zimmerman, the coordinator of Dataspeak and the moderator for today's program. Beth, I'll turn it over to you now.

>> BETH ZIMMERMAN: Thank you so much, Dr. Overpeck, and welcome to all our participants. Before we hear from our presenters, I have just a few tips I'd like to share to help make the most of today's program. First I want to be sure that everyone knows how to access the visuals that have been prepared to accompany our two presentations. Those of you who are listening to the broadcast through the Internet will be shown a slide presentation coordinated with the presenters' remarks. You can also view the slides within the slide show section of the Dataspeak web site, where you can manually scroll through it as the presenters talk -- and that's an option that's open to folks on the telephone as well. A third option is to download the PowerPoint files and view them through that program. For anyone who needs the Dataspeak web site address, it is www.uic.edu/sph/dataspeak. I also want to point out that in order to coordinate the presenter's' remarks with their slides for the Internet broadcast and for the archives their presentations have been prerecorded. After we hear both of their presentations we'll have a question and answer session. Those of you on the phone will have an opportunity to ask questions at that time through the operator, and, in addition, everyone can pose questions at any time during the program through the WebBoard on the Dataspeak web site. To post a question online or to read what others have posted from the Dataspeak web site you just click on the link that says "Read and submit questions and answers."

Now it's my pleasure to introduce our first presenter, Dr. Julie Hudman. Dr. Hudman is the Associate Director of the Kaiser Commission on Medicaid and the Uninsured, which is a national nonpartisan commission that serves as a policy institute and forum for analyzing health care coverage and access for low-income populations, and assessing options for reform. The Commission has developed several publications highlighting issues around health coverage and access to care for immigrant populations and we're fortunate to have Dr. Hudman with us. Julie, I will now turn the floor over to you.

Immigrants' Health Care: Issues Related to Coverage and Access
Julie Hudman, PhD
Kaiser Commission on Medicaid and the Uninsured

Thank you. I'm very happy to be here today, and to talk to you all about immigrants and their health care coverage and access. Next slide. We first want to spend a little bit more time just talking more broadly about immigrants in the United States and a lot of groups I talk to don't know a lot about immigrants. They're more familiar with general health care coverage and access issues, so I want to spend a little time on background and provide some basic data about typical immigrants. Next slide, please.

In Figure 2, you can see that immigrants made up over 11% of the nation's population in 2000. The percent of immigrants in the U.S. has been steadily increasing since 1970 when only about 4.7% of the population consisted of immigrants. However, you have to go back over 100 years in history to around 1900 and the time of the industrial revolution to see when immigrants made up the most significant percent of the U.S. population. At that time about 15% of the population was foreign-born. The next slide, Figure 3, shows the country of origin for the U.S. immigrant population over the past 100 years, which you'll notice immediately that there's been dramatic changes in where immigrants in America are coming from. As you can see in 1900, 86% of all immigrants came from Europe, but in the year 2000, only 15% of immigrants came from Europe. In 2000, Latin America, which includes Mexico, was the birthplace for over half of all immigrants in the United States.

Figure 4 displays what states immigrants live in in the United States. Almost a third of all immigrants live in California, and 40% of immigrants live in either New York, Florida, Texas, New Jersey, or Illinois. However, 30% of immigrants, the remaining portion, are dispersed across the rest of the country with states such as North Carolina, Nevada, Kansas, and Indiana all experiencing over 50% increases in their foreign-born population since 1995.

Figure 5 displays the different type of legal status of immigrants. There's several different categories, and immigrants fall into one of these categories, depending on how they came to the United States and their current citizenship status. As you can see, over 70% of the foreign-born population in the U.S. are here legally, with most of those coming to join family members. The remaining share, 28%, are undocumented immigrants. About 30 to 40% of these undocumented immigrants did enter the country legally, however, became illegal when they stayed past their visa. Issues of legal status are very important, as we'll discuss later, especially when talking about issues regarding eligibility for public programs and access to care.

Figure 6 shows us that noncitizens are just about as likely to have a full-time worker in their family as citizens. However they are much more likely to be poor. The reason they are poor is probably because they're more likely to work for small businesses, and they're more likely to work in fields such as agriculture, labor, cleaning, craft, and repair, and much less likely to work in more of the administration, the managerial, the sales, or tech jobs. Next slide, please.

Now I want to spend some time talking about the programs and the policies that affects immigrants' health care coverage. Figure 8 talks about the Medicaid's role in the health system, and as you will see later in the presentation, the Medicaid program plays a large role for immigrants, especially pregnant women and children, as the main safety net program for a low-income population. Medicaid today covers about 10% of the U.S. population, including 20% of all children, or 22 million children. Medicare also pays for about 40% of all births in the United States. This is due to states expanding the Medicaid coverage for pregnant women beginning back in the 1980's. The CHIP program, which began in 1997 and can either be a Medicaid expansion or a separate state health insurance program, covers another 3.5 million kids. Medicaid provides a comprehensive benefit package several benefits including inpatient hospital care, immunizations, EPSDT services for children, family planning services, prescription drugs, dental, and vision care. We also know from research that Medicaid improves access to physician services and preventive care for the low-income population, and it also facilitates access to prenatal care. Next slide.

There's been some major policy changes in the last several years that affect immigrants' access to public programs, including Medicaid. Figure 9 details the most important recent policy change that affects immigrants. The personal responsibility and Work Opportunity Reconciliation Act of 1996 which is better known as welfare reform fundamentally changed cash assistance but also made major changes affecting which immigrants can receive Medicaid coverage. Previously, before welfare reform, all legal permanent residents and other legal immigrants had the same access to public benefits including Medicaid as did U.S. citizens. However welfare reform created a five-year ban on Medicaid for immigrants arriving after 1996. Undocumented immigrants have never been able to receive Medicaid except in emergency care situations, and that remains the case after welfare reform. Other policies also affect immigrants' access to health care coverage such as deeming resources -- this deeming can cause many immigrants to not be eligible even after the five-year ban.

The next slide looks at state-only funding of legal immigrants, and after welfare reform many states decided to go ahead and provide Medicaid and CHIP with their own funds for immigrants that arrived after 1996. As we said before, they were not allowed to receive federal matching funds for these populations. Seventeen states provide Medicaid and 13 states provide CHIP coverage for legal immigrant children, and 18 states provide Medicare for pregnant women, even though the state will not receive any federal funding to do so. Also, 12 states provide prenatal care to immigrant women regardless of if they are undocumented or if they were here after August of 1996. Next slide.

Now I want to spend some time talking about how immigrant status can affect health coverage.
Figure 12 shows the latest data for immigrants' health care coverage. As you'll see on the left side of this slide, low-income noncitizens are twice as likely to be uninsured as are low income citizens. Almost 60% of low-income noncitizens have no health insurance coverage. They also are much less likely to have Medicaid. Only 15% of low-income noncitizens have Medicaid, whereas 28% of citizens do. Adult men are the most likely noncitizens to be uninsured. This is most likely due to their low rates of Medicaid coverage, which for year 2000 was 8% of low income adult men received Medicaid coverage. Children fare much better with over a quarter of low-income noncitizen children receiving Medicaid.

Figure 13 shows low income noncitizens health insurance coverage over the past five years. As you see in the slide, low-income noncitizens' high rates of uninsurance have gotten worse since 1995, the year before welfare reform was implemented. In addition more immigrants receive Medicaid in 1995 compared to 2000.

Figure 14 looks at the over 24 million low-income uninsured and looks at the difference in citizenship status. As you can see, immigrants make up about 27% of the low-income uninsured, with noncitizens who have been here for six years or more consisting of 13% of all of the low income inn insured. U.S.-born citizens make up about 73% of the low-income uninsured.

Figure 15 looks at parents' immigrant status and how that might affect their children. Children who are born to immigrants, despite typically being U.S. citizens themselves, are much more likely to face barriers to health coverage and accessing services and are much more likely to be in worse health than children who are born to U.S. citizens. So even if the children are U.S. citizens, if they live in an immigrant family, they tend to have worse health access and worse health coverage and health status than children who are born to U.S. citizens.

The next slide shows there are some major factors that play a role in immigrant children's health care coverage. Language spoken at home and citizenship status. Children in the citizen family where English is the primary language are less likely to be uninsured than children in a similar type of family that speaks Spanish at home. And almost three-quarters of children that are noncitizen families and speak Spanish at home are uninsured.

Figure 17 summarizes the barriers for immigrants to qualify and enroll in Medicaid or CHIP. As mentioned before, immigrants arriving after August 1996 and are not eligible for federal funds for Medicaid or CHIP for five years unless they happen to live in a state with a state replacement program for immigrants. If they live in one of these states then they will receive Medicaid or CHIP. Many immigrants are not eligible for Medicaid or CHIP not only because of their immigrant status, but because of some of the eligibility gaps in Medicaid. Also, undocumented immigrants, a small but significant portion of immigrants in the U.S., are not eligible for Medicaid and CHIP. While these eligibility barriers are a matter of stated policy, many enrollment barriers that exist relate more to implementation and misinformation than they do to stated policies. Barriers such as language, feelings of discrimination, and fear experience with immigrants prevents them from enrolling into public programs.
Next slide, please.

Finally, I want to talk about immigrant status and how it affects access to health care services. We've already established that immigrants are much less likely to have health insurance coverage, but the next set of slides we'll look at how it affects their ability to get health care.
Next slide.

Figure 19 shows that having a usual source of care varies by citizenship status. Low-income adults, 37% of noncitizens reported not having a usual source of care, compared to 19% of low-income citizens. Most noncitizens reported going to a clinic as their main source of care, whereas citizens are much more likely to go to a doctor's office to receive care. Despite the lack of a regular place to go to receive health care services, noncitizens are are not more likely to go to an emergency than citizens were.

The next slide shows that utilization of health services also varies by citizenship status. This data shows a striking difference between citizens and noncitizen children's medical visits. Noncitizen children average 1.5 provider visits a year, while citizen children with citizen parents average over twice as many visits. They saw a doctor 3.7 times a year. As you can see, there's also variation in dental visits and mental health visits. Noncitizen children were also less likely to visit emergency rooms than were citizen children.

Figure 21 shows that race and language spoken at home do not seem to make a big difference regarding low income children's doctor visits. However, language seems to be important in families with mixed citizenship status or in families that are all noncitizen. Only 29% of children in noncitizen families who spoke Spanish at home saw a doctor last year. This is compared to 71% of low-income white children in citizen families who speak English at home.
Next slide.

There are several key issues spacing immigrant populations. Some of the issues are the changes in where immigrants come from and where they settle, changes in the lack of health care coverage, and more and more immigrants becoming uninsured, and less and less immigrants being eligible for Medicaid. Barriers for accessing health services. One of the major barriers being language. Policies that treat new immigrants differently. Before August of 1996 and welfare reform, legal permanent residents had all the rights and responsibilities and access to all the programs that U.S. citizens had. However, after 1996, now legal permanent residents must wait for five years regardless of how poor or how sick they are, before they could access Medicaid or CHIP. And, finally, the constantly changing political environment and the economy is going to have a major factor in immigrants' ability to have health care coverage or to access health care services.

I'm going to stop there and look forward to talking to you all and answering any questions you may have. Thank you.

Acculturation and the Health and Well-Being of U.S. Immigrant Adolescents
Stella Yu, ScD
Maternal and Child Health Bureau

>> BETH ZIMMERMAN: Thank you very much, Julie. That was a very interesting and informative overview. We now have the opportunity to hear from Dr. Stella Yu of the Maternal and Child Health Bureau, who, in addition to being a presenter today, is also the project officer of the MCH Information Resource Center under which Dataspeak is operated. Doctor Yu will be sharing findings from the Bureau's recent work on the health of children of immigrants. Stella, I'll now turn the floor over to you.

>> STELLA YU: I'm very glad to have the opportunity to report on the work our group has been doing on the subject of immigrant children. Specifically, I'll be discussing our project on acculturation and the health and well-being of immigrant adolescents in some detail today. I'd like to first acknowledge my co-authors, Dr. Jen Huang, Renee Schwalberg, Dr. Mary Overpeck, and Dr. Michael Kogan. Next slide.

Nearly 14 million children in the United States are immigrants or have immigrant parents in Year 2000, and almost one in six children under 18 live with a foreign-born householder. More than 30 million Americans were estimated to be foreign-born in Year 2000. The population of children in immigrants families has grown by almost 50% over the course of the 1990's -- nearly seven times faster than the population of children of U.S.-born parents. While the majority of children in immigrant families are of Hispanic or Asian origin, the growing population of immigrant children also includes significant numbers of recently arrived refugees from eastern Europe and Africa.

Children in immigrant families are more likely than native-born children to be poor, to live in crowded housing, to be uninsured, to lack a usual source of health care, and to be in poor health. For adolescents, being foreign born or residing in a foreign-born household produces stresses that may be reflected in the health behaviors and risk factors. Because of the paucity of research on the effects of immigration and children's health, the IOM committee on the health and adjustment of immigrant children and families has recommended that research be conducted on the physical health, mental health, and school adjustment of immigrant children. Our study directly addresses this topic.Next slide.

Due to their different cultural backgrounds and countries of origin, the effect of acculturation on adolescents' status is likely to vary by race and ethnicity. The objectives of our study are to estimate the prevalence of the health, psychosocial, and parental risk factors by race, ethnicity, and language groups, and to examine the association of these factors with the degree of acculturation as measured by language at home. I want to note here that all data presented are compared to non-Hispanic, white English speakers which I will refer to as "the reference group" from now on. Next slide, please.

The data used in this study are drawn from the 1997 to '98 WHO Study of Health Behavior in School Children, a cross-sectional survey focusing on the health status, health behaviors, and lifestyles of young people. This is a nationally representative sample of youth in grades 6 to 10 in U.S. schools. The NICHD supported the U.S. component during the spring of '98. The subjects included students who answered anonymous standardized questionnaires from 386 schools. The participation rate was 83%. Next slide, please.

Records were selected for respondents between the age of 11 and 17 in four racial ethnic groups. The non-Hispanic white, non-Hispanic blacks, Hispanics and Asians, a total of 15,220 records were analyzed. Next slide.

The outcome measures of well-being included questions about health behavior (including seat belt and helmet use), frequency of adversities (such as stomachaches and overall developments), psychosocial and school risk factors (such as acceptance from other students and support from teachers), and parental influence such as perception of parents' willingness to help, and difficulty talking to parents about problems. The independent variable is the language the child reports speaking at home all or most of the time. The students were classified in three groups based on the primary language they reported speaking at home: Those who usually speak English, those who usually speak a language other than English, and those who speak English and another language about equally. Adjustment variables include age, gender, and mother's education from the questionnaire. In the multivaried analyses, responses from all groups were compared to that of the English-speaking white population to create odds ratios that may be compared across racial ethnic groups. All analyses were conducted using the Sudan software. Next slide.

More than 30% of Asians and nearly 20% of Hispanic respondents were foreign-born compared to 2.5% of non-Hispanic whites and 2.3% of non-Hispanic blacks. Asians and Hispanics were also the most likely to speak another language other than English at home. One quarter of Hispanic and Asian respondents reported that they do not usually speak English at home, and about 45% of respondents in each group speak two languages about equally.
Next slide.

The next few slides show the result of multivaried analyses that compare the level of risk in each racioethnic and language group to that of the reference group, controlling for the effect of age, gender, and maternal education. We're only showing few selected variables as examples.
White adolescents who are not primarily English speakers have increased levels of risk for a small number of psychosocial and parental risk factors. Those who primarily speak another language at home have significantly increased risks of being bullied because of their race or religion, and are twice as likely to report not to receive parental help, or their parents are not willing to talk to teachers. They also felt that their parents expected too much of them at school. Those who speak a mixture of languages at home also reported a twofold risk of being bullied, high teacher expectations, and not feeling safe at school. Next slide.

Among non-Hispanic black students, increased risk was seen for health, psychosocial, and parental risk factors when compared to the reference group. However, these risks were high for all three language groups. Black adolescents are at significantly higher risk for all factors regardless of the language they speak at home. The odds ratios for these risk factors are highest among those who speak mixture of languages and lowest among those who speak another language exclusively.

In the next slide, we showed data on the Hispanic respondents where you can see the pattern is reversed. Adolescents who speak Spanish at home experience higher levels of risk for more factors than bilingual or English-speaking Hispanic youth. Spanish-speaking adolescents are about twice as likely not to wear bicycle helmets, to report not feeling confident, to be bullied at school, and to feel excessive adolescent expectations. English-speaking Hispanic respondents had an odds ratio of 1.8 for being bullied but did not experience increased risk of other factors.

Our next slide shows that the pattern among Asian respondents was similar. Those who speak another language exclusively at home have significantly higher rates of a wide range of risk factors, including dizziness, difficulty making new friends, not spending evenings with friends, being bullied, not receiving help from parents, and feeling that parents are not often willing to talk to their teachers about problems at school. Those who speak mixed languages had increased risk for fewer factors, predominantly psychosocial and parental. English-speaking Asian-American adolescents experienced higher risk of being bullied at school because of their race or religion.

In the next few slides we'll be showing you the odds ratios and confidence intervals of a number of risk factors across ethnic groups, which demonstrates that regardless of race or ethnicity, students who primarily speak another language at home had significantly greater odds of reporting several parental risk factors. Next slide.

As the next slide shows, the odds of students reporting that parents were not ready to help them were higher for all non-English speakers compared to the reference group. Next slide.

The same pattern is found for students reporting that their parents expect too much of them. Next slide.

Perhaps not surprisingly, students who do not speak English at home also have higher odds of reporting that their parents are not willing to talk to their teachers. Next slide, please.

Non-English speakers also reported higher odds of being victims of violence. Students in all racial and ethnic groups who spoke another language at home were more likely than white non-Hispanic English speakers to report being bullied at school. Next slide.

Similarly, non-English speakers also had higher odds of not feeling safe at school. Next slide, please.

This analysis demonstrates the complex interaction among immigration, race, ethnicity and linguistic assimilation. Adolescents of all racial and ethnic groups who do not speak English at home are at higher risk of a range of psychosocial and parental risk factors, compared to the majority population of white English speakers. Adolescents who speak other languages at home exclusively or in combination with English are particularly likely to report feelings of vulnerability, exclusion, and lack of confidence. In addition, it is notable that all non-white youth, regardless of language, and white adolescents who do not speak English exclusively, or at significantly higher risk for being bullied at school because of their race or religion. This study reinforces the conclusion that neither acculturation nor ethnicity alone determines the risk faced by immigrant youth. The growing diversity of American culture does not necessarily protect adolescents whose families are new to the United States from feeling alienated from their schools and their classmates.

In addition, parents may provide a particularly weak support system for these children, as they are often even less acculturated than their children and often even rely on them for support. Furthermore, immigrant parents may experience both linguistic and cultural barriers in communicating with children who grew up in the United States and their children in turn may experience conflicts if they are surrounded by different cultures and expectations at home and in the wider world. Next slide, please.

Several limitations of this analysis should be noted. First, because the survey was conducted in schools, the study population excludes those who have dropped out or who are in juvenile justice systems. Therefore, the levels of risk reported here may be lower than those of the adolescent population as a whole. Absenteeism may also tend to bias risk levels downward. The survey does not provide information on respondents' citizenship or the length of time they have been in the U.S., and this may affect the ability to access federal programs. Next slide.

The study highlights many of the issues and challenges faced by adolescents from different levels of acculturation in the U.S., a nation that prides itself in its diversity and its legacy of immigration. As demonstrated by subgroup analysis, some general patterns about children who live in foreign-born households emerge, but further research is needed to examine the details of the specific ethnic groups to ensure that all youth have the potential for enjoying optimal physical and mental health. These findings also emphasize the need to design risk reduction interventions that take the vulnerabilities of immigrant youth into account.
Well, thank you for listening.

Questions & Answers
moderated by Beth Zimmerman, MCH Information Resource Center

>> BETH ZIMMERMAN: Thank you very much, Stella. Your study has some really interesting findings and I appreciate your sharing them with us. I also want to welcome everybody to the question and answer section of our program. We have our two presenters with us to answer questions as well as Dr. Jennifer Huang, who is a co-author on this study that Stella just presented on, from The Children's National Medical Center, as well as Dr. Mary Overpeck, who welcomed us at the beginning of the program.

As I mentioned at the beginning, we'll be able to take questions both from our telephone participants as well as through the Dataspeak web site. ... While folks on the telephone are putting in their requests, I would like to go ahead and look at the questions that have already been posted on our web site. I appreciate folks for doing that. And I'd like to ask a first question of Dr. Hudman. Julie, let's focus for a second on this particular issue of working immigrants. Can you talk about why working immigrants are often not receiving health insurance coverage?

>> JULIE HUDMAN: Sure. One of the major reasons is why typically low-income working populations generally are uninsured, and immigrants just happen to fall into that group, whereas we see most of our uninsured population, 40 to 44 million -- around 40 million, most of those people are working, and immigrants are included in that. But what happened is that most of those workers are not offered coverage at their job place. The ones that are offered usually do not participate because of cost reasons. In some of theother work we've done and looked at, how much these premiums are and what are the participation rates, and if people are interested in that, I can direct them where to go. But it's just typically the type of job that they have in the service sector or it might be in construction work or other things where we just don't see a lot of employer sponsored coverage generally, having nothing to do with being an immigrant or not.

>> BETH ZIMMERMAN: Alright, yes, so again the same problems at other low-income folks have with insurance.

>> JULIE HUDMAN: Absolutely.

>> BETH ZIMMERMAN: Would you like to take an opportunity just to say about what's available on your web site?

>> JULIE HUDMAN: Sure. Our main web site is www.kff.org -- that's the Kaiser Family Foundation web site and the Kaiser Commission on Medicaid and the Uninsured is one of the buttons on the web site you can push and get into all of our information. And you'll see most of the latest immigrant publications that we have I think you all noted on the Dataspeak web site. We're actually going to have a couple new publications coming out in the next couple of months, both dealing with language issues around immigrants and also dealing with how many immigrants were really affected by welfare reform and how many do we think are going to be affected in the future. Those are a couple of the projects we have coming out. We also are going to have a survey and some in-depth analysis of certain states that have gone forward and went ahead and funded state-only health care programs, Medicaid or CHIP or prenatal care programs, and we're going to do some case study analysis to try to figure out why certain states such as California moved forward and funded with their own money the Medicaid program for immigrants that arrived at 1996 where other states that serve a lot of immigrants decided not to do that. And so we're going to try to compare, you know, what were the reasons for doing that, what have they found out has been beneficial, and, you know, the issues related to not covering, or also covering the immigrants.

And with state budgets having a lot of problems recently, a lot of states are experiencing budget overruns for a lot of different reasons. We're wanting to look at some of these programs and seeing if they survive some of the budget cuts that are happening right now in the states.

>> BETH ZIMMERMAN: Interesting question at an interesting time. So thank you. So we've put a link on the Dataspeak web site to the Kaiser Commission, for their reports, and it sounds like there will be a lot of new ones coming out. Thanks for giving us that information.

>> JULIE HUDMAN: Sure.

>> BETH ZIMMERMAN: I will continue with the questions that we have on our web site, and I'd like to ask Mary, if you could please give us a little bit more background about the survey from which the data for this study was gathered.

>> MARY OVERPECK: Okay, thank you. I'd be delighted to tell you about the WHO Study of Health Behavior in School-aged Children, which is the source of data for Stella's analysis. It is a cross-national research study which aims to gain new insight and an increased understanding of adolescent health behaviors, health and lifestyles in their social context. The survey is performed every four years and currently includes about 35 countries. The collaborative study includes nationally represented surveys of students ages 11, 13, and 15 years of age. Students are surveyed in a classroom setting. The study goal is to use the information to improve long-term health consequences resulting from adolescent behavior and the quality of health promotion programs and services for youth.

The U.S. survey is sponsored by the Maternal and Child Health Bureau and the National Institute of Child Health and Human Development. The U.S. participated in the international study for the first time during the 1997-98 school year. Although it has been completed in other countries since 1984, each country must field a survey using a set of mandatory questions with modifications allowed only to adjust for consistency with language and cultural content. We may add additional questions only if time allows for a student to complete the survey.

The U.S. added questions on race, ethnicity, parental education, place of birth, and primary language spoken in the home. These questions are not part of surveys in other countries. For doctor-youth analysis of students whose parents speak another primary language in the home it is important to note that the survey is administered in regular classrooms at grades 6 to 10. Students who are in special programs possibly because of special learning needs such as language and reading skills would probably not be included in the study.

Also, if they have trouble completing standardized questionnaires, they are less likely to respond. Therefore the prevalence of attributes associated with acculturation may be higher than reported in the survey. The 1998 survey used for Stella's presentation is being submitted to the University of Michigan Inter-University Consortium for Political and Social Research web site to make it publicly available. In the meantime, a 1996 U.S. nationally representative survey, including similar questions related to acculturation and performed by the Substance Abuse and Mental Health Administration is available at the same University of Michigan web site which is available from other sources. Are there any questions?

>> BETH ZIMMERMAN: So the data that's being presented on the University of Michigan web site, are those going to be public use files that folks can do their own data analysis on?

>> MARY OVERPECK: Yes, they are going to be public use files.

>> BETH ZIMMERMAN: Okay. And you mentioned that we participated for the first time in the 1997-98 school year. Are there plans for us to do another round and get some updated data?

>> MARY OVERPECK: Yes. We just completed the survey for 2002 and are getting ready to submit our data to make sure that we're comparable to the other countries who are doing it at the same time.

>> BETH ZIMMERMAN: Thank you. Anybody else have any questions about this survey? ... There is a new question we have just posted on the web site from Shaney Mason in Oregon. Thanks, Shaney. She asks, is there a difference in the funding levels of public health programs that serve immigrants versus programs that have citizenship restrictions? I'm not sure. Julie, do you know?

>> JULIE HUDMAN: I can take a shot at that. Like I said, before August of 1996 there wasn't really any distinction in most programs on a citizenship basis. They just served anybody who was legally here regardless of where they were born as long as they were a legal permanent resident or refugee or naturalized citizen, they, you know, received the same services. We didn't have to have special programs for immigrants per se. There are some targeted programs run out of HHS that target certain populations, whether they be low-income or a certain ethnicity or in a certain community, and some of those might have been targeted at immigrants.

And so you might see some special programs, those are pretty small typically compared to, say, the Medicaid program. And now -- but we have seen now that states are having to run some programs that are just for immigrants, and -- before they would receive federal funding for that, and now they're not able to. And so, you know, is the level of funding different? It is in some ways because of some of the laws have made some of the pots of money have to be split up differently. Do immigrants get more or less funding? I guess I would say that they would get less funding generally just because of some of the restrictions that have been placed on it, even though some states have, like I said, step-up and funded programs, I would assume that a lot of immigrants, especially ones who are not here legally, are left out of a lot of accessing a lot of public programs.

>> BETH ZIMMERMAN: Will your case study look at funding levels for the different state programs?

>> JULIE HUDMAN: Absolutely. That's one of the factors we're going to look at. We'd like to do it in all 50 states. We're going to start off just looking at, like I said, a handful of states, probably a couple of the big immigrant states -- California, Texas, New York. And then also some of what are considered the new immigrant states, states that don't have a large number of immigrants per se but they have a growing, growing increase in the number of immigrants, and this would be North Carolina -- we see a lot of immigrants who have moved there to work in the poultry, you know, manufacture industry and we also see a lot that have moved there to work in the fields and to work in agriculture; another state -- such as Nevada -- has had a huge growth and a lot of their growth is in the hotel sector and that's where immigrants are working. And so we'd like to look at a couple of states that have had a lot of new immigrants and see, you know, what kind of health programs they are running on the ground level, what kind of health services they are providing to this new population.

>> BETH ZIMMERMAN: Thanks, Julie. There's another question on the web site about the use of language at home as the predictor in the study that Dr. Yu talked about. I'd like to ask actually Dr. Huang, one of the co-authors on the study, if you could address why the decision was made to use language at home instead of birthplace as the predictor in your study.

>> JENNIFER HUANG: Sure, all of the variables from this study came from WHO Study of Health Behaviors in School Children. The data just now that Mary has described in detail.
Well, this survey contains only two questions on grant status. One is whether they are U.S.-born. The second one is what language do your parents or other people who are raising you speak at home? So the students are classified in three groups based on the language they reported speaking at home. Those who usually speak English; those who usually speak a language other than English; and those who speak English and other language about equally.

So in this study we feel that the language at home is a more sensitive measure of acculturation because it will distinguish children who are born in the U.S. but live in a home who do not speak English as compared to the children from native families. So we have this assumption that the family speaks only English will be either native or immigrant -- native family or immigrant family -- who has been in the U.S. for a long time. So they will have very few barriers to communication with school and health professionals.

And a family which usually only speaks other languages are usually the most recent immigrants. And a family who speaks English and another language equally are more likely to be the immigrant family that contains both first and second generations of immigrants.

>> BETH ZIMMERMAN: It's more like a gradient.

>> JENNIFER HUANG: Yes, exactly.

>> BETH ZIMMERMAN: That makes sense. Thank you very much. There is another question on our web site from Tamara Munoz. She asks, "Do you have any information on the percentage of European immigrants that access health care?" I guess trying to get at the differences we see in access to care for immigrants from different places.

>> JULIE HUDMAN: Sure. I don't have any information right at my fingertips. I was thinking of the question when I saw it posted. But one way I could get to that answer, and I'll be happy to get back to her, is you can look at some of the CPS data, the Current Population Survey data, which we look at, and some of the data I presented, it's from that, where it's citizen and noncitizen, and what you can do is also look at a variable on race and ethnicity. It's not a perfect way to do it, but you can look at people who report being white and who are noncitizens, and then you can look at some health insurance coverage and very general access to care issues. And like I said, I'd be happy to get some basic information back to her, if she has a more specific question on that. If she just wants some basic data, I could probably come up with that.

>> BETH ZIMMERMAN: Great. Maybe what you could do is just do a quick response on the web site.

>> JULIE HUDMAN: Sure.

>> BETH ZIMMERMAN: And then she could get back, if needed. If folks do want to follow up after the program with presenters, we do have presenter contact information posted on the web site, so you can e-mail a question or a call. Thank you. We have another question from Diana Miller. She was asking about what information we have available about the free services that are being provided, including private funding or gratis services that are not state or federally regulated or monitored. And she notes that the State University Hospital here, I believe these in North Carolina, will treat immigrant families with disabled and sick children with a high level of success. So it's sort of, I guess, that separate system through which services may be provided that's not being monitored through our state and federally funded programs.

>> JULIE HUDMAN: Well, I'm happy to comment on that. She's absolutely right. Hospitals, public hospitals especially, but also nonprofit hospitals -- anybody who receives federal funding, which most hospitals do if they see Medicare patients or Medicaid patients -- must see immigrants or anyone, for that matter, if there's an emergency situation. And then if the hospital chooses or has a mission to, you know, go ahead and continue seeing these families, then the financing to pay for that might come out of a local financing mechanism; it might come out of what they use as charity care, and that won't be necessarily reimbursed from the federal government. So there is a lot of -- I don't know if there's a lot, but there is definitely some services that immigrants receive that are provided free to them, and then the provider is, you know, finding funding to pay for those services from another source.

Community health centers are another very good example and probably see the bulk of uninsured noncitizens because of their mission generally, especially the federally qualified community health centers must see anyone, regardless of health insurance status or immigrant status. And so what happens here, if we have more and more immigrants who don't have health coverage, we'll see more of them going to these community health centers, which will then have a strain on some of their funding. And so it's not just adjusted -- that people are not necessarily receiving services, but we know from the research that if you're uninsured you typically will receive services at a later date and at a date when your health care situation might be in a worse manner than it would have been if you had seen regular primary or preventive care. And I'm sure there's probably a ton of programs happening on the local level, and that's one of the things we're going to try to find out, that provide services to these families. It sounds like there's a good one in North Carolina.

>> BETH ZIMMERMAN: There you go. So you can follow up. Thanks for being that contact.
There's actually two questions posted on the web site about language. One has to do with asking why is language a barrier to access of health care services; another having to do about the accessibility of interpreter services for agencies that are providing health care to immigrants. Can you comment on that as well, Julie?

>> JULIE HUDMAN: Yes. Let me start with the second one. The question of interpreter services is an interesting one and one of our new studies, our new analysis coming out in a month or so, is about this issue. There's some federal regulation that stated that if the provider receives some federal funding, that they have to provide some sort of reasonable interpretation for people who don't speak English. And how this really is playing out on the ground level with providers is unclear, and I don't think our study will actually answer how it's playing out. That's going to be difficult to find out. But what we are trying to do is trying to figure out exactly what providers by law and by regulation need to do. And there's been some -- it kind of runs the gamut of how people -- how they interpret this -- this regulation. And there's 1-800 numbers, there's call-AT&T kind of translation lines that people can use and providers can use to help try to talk to their patients who don't speak English.

There is some other people who believe that just providing some paper in the language of the person and explaining to them the situation is another appropriate way to provide that kind of interpreter services. But what we do know from the research is that people who don't speak English as their first language have much worse access issues and then much more worse outcomes. And this is going to continue to be a big problem. I don't know a lot about how it's working in the education system, but I know trying to take classes in English as a second language is a very difficult issue, too, and there's been some problems on that end. So this is going to continue being a problem, and if we want people to get the health care that they need, that somehow this interpretation services and helping people receive services, if they don't speak English, is going to continue to be an issue. And I don't think there's an easy answer. I wish there was.

>> BETH ZIMMERMAN: Especially given the diversity of language --

>> JULIE HUDMAN: Absolutely. We hear of stories and we've done some focus groups, you know, with Cantonese-speaking immigrants in New York, and they all know which provider to go to so they can receive their services. But if something happens or they're not in their community or they're traveling or something, you know, that person is not available to them, then it becomes a big barrier, and we see the people trying to go to places that they can access services and that they can speak to the people who are seeing them. But it doesn't always work out.

>> BETH ZIMMERMAN: Yeah. Alright, thank you. It's a tough issue. I'm sure lots of people will continue to grapple with that both at the policy level and obviously at the direct service level.

>> JOSEPHINE MERCADO: Good afternoon. I'm calling from Orlando, Florida. I'm wondering whether or not the case study that she was speaking about will also include Florida.

>> JULIE HUDMAN: We haven't picked our states yet to tell you the truth. Obviously Florida is going to be at the top of our list. One of the issues is we want to pick some states that have done some big state programs for immigrants, and Florida, at least on level with California has not done that. They haven't provided Medicare in the same way that like the state of California has, but in some ways that makes it almost more interesting to go there and to use that as a case study because Florida has so many immigrants. And so to see what are maybe some local, you know, community providers doing, what are happening in different cities, and also to find out why the state chose not to put up the state funds to do. Obviously it's a funding issue generally, but other states went ahead and did that. So we're trying to do short ol what those states will be, and I don't know if you have any knowledge about different things that are going on.

>> JOSEPHINE MERCADO: We're right now looking at the problem at the community level, specifically the County of Orange, and that's why I was interested in whether or not Florida would be included. And I certainly would like to help you if I can in any way.

>> JULIE HUDMAN: Sure. If you would send me your information via e-mail, that would be great. And if we move forward with Florida -- I mean this issue is going to be here whether or not we work with Florida on this study or not. We are very committed to doing a lot of projects around these issues, around immigrants and just mainly because our mission is to look at low-income populations and immigrants make up part of that and they also have a lot of other -- you know, other barriers including their language and other things, so we will continue to be doing work around this area. So I appreciate that.

>> BETH ZIMMERMAN: Thanks for your call. Well, we are actually at the end of our program, and I appreciate the great discussion that we've had here today. We will be archiving this program on the Dataspeak web site in the next few days so that you can access it to your convenience, so that others might be interested in the topic that this is available to them. You will be receiving an e-mail this afternoon asking for your feedback on today's program. Again, it is the last one in our 2002 Spring Series and we'd really appreciate if you'd take a moment to respond. Thank you so much to our presenters and their colleagues, Dr. Julie Hudman, Stella Yu, Mary Overpeck, and Jennifer Huang. And of course my thanks to all of you in our audience pour participating in today's programs as well as the other programs we've had in our series. Thank you, and the audio conference is now officially adjourned.