Disparities in Access to Health Care Among US-Bornand Foreig.docx

Disparities in Access to Health Care Among US-Born
and Foreign-Born US Adults by Mental Health
Status, 2013–2016
Reema Dedania, MD, MPH, and Gilbert Gonzales, PhD, MHA
Objectives. To compare access to care between US-born and
foreign-born US adults
by mental health status.
Methods. We analyzed data on nonelderly adults (n = 100 428)
from the 2013–2016
National Health Interview Survey. We used prevalence
estimates and multivariable lo-
gistic regression models to compare issues of affordability and
accessibility between
US-born and foreign-born individuals.
Results. Approximately 22.2% of US-born adults and 18.1% of
foreign-born adults
had symptoms of moderate to severe psychological distress.
Compared with US-born
adults with no psychological distress, and after adjustment for
sociodemographic
characteristics, US-born and foreign-born adults with

psychological distress were much
more likely to report multiple emergency room visits and unmet
medical care, mental
health care, and prescription medications because of cost.
Conclusions. Our study found that adults with moderate to
severe psychological
distress, regardless of their immigration status, were at greater
risk for reporting issues
of affordability when accessing health care compared with US-
born adults with no
psychological distress.
Public Health Implications. Health care and mental health
reforms should focus
on reducing health care costs and establishing innovative efforts
to broaden access to
care to diverse populations. (Am J Public Health.
2019;109:S221–S227. doi:10.2105/
AJPH.2019.305149)
Health care access is an important factorassociated with mental
illness pre-
vention, early-stage diagnosis and treatment,
and overall prognosis of psychiatric disorders.1
However, disparities in health care access and
health services utilization between immi-

grants and native-born populations in the
United States have been well documented for
a number of reasons, including stigmatization,
fear of deportation, challenges navigating a
complex health insurance system, and the
absence of culturally sensitive care and health
information.2,3 Studies show that, on average,
immigrants report better self-rated health and
less health services utilization compared with
native-born populations. However, consid-
erable debate remains over whether lower
utilization rates reflect a lesser need or an issue
of accessibility.4–7 This problem can be
unremitting and even aggravated in the
treatment of mental health disorders, which
are among the most expensive medical con-
ditions in the United States in recent years.8
There are a variety of factors that influence
the mental health of immigrants in particu-
lar. First, it is essential to recognize that
immigrants enter the United States through
a variety of means, including elective immi-
gration (e.g., family-based and employment-
based immigration) and forced migration
(e.g., refugees or asylees who are fleeing
persecution or are unable to return to their
homeland because of life-threatening and
oftentimes extraordinary conditions).
Depending on the reason for relocation,
immigrants may experience resettlement
stress during the acclimation and adjust-
ment period caused by changes in socio-
economic status. Isolation and absence of

social support may also serve as catalysts for
undue stress to develop into persistent psy-
chiatric pathology and reduced quality of
life.9,10 Furthermore, traumatic and adverse
life experiences, particularly in the refugee
and asylee population, serve as forerunners
for acute stress disorder and posttraumatic
stress disorder in these groups.9,10 Because
immigrants and children of immigrants
constitute 24% of the US population,11 their
mental health concerns—and acculturative
stress in particular—have ramifications for the
overall health of the nation.
Although immigrants may have greater
mental health care needs, barriers to medical
and mental health care may prevent some
immigrants from accessing needed treatment.
For instance, immigrants are at higher risk for
encountering hostile attitudes in the health
care delivery system,12 which impedes access
to routine medical care for this vulnerable
population. Evidence suggests that height-
ened vigilance related to perceived prejudice
also has pathogenic effects on the mental
health of immigrant populations.12 A recent
study of Hispanics in 38 states found higher
rates of mental illness in states with more
ABOUT THE AUTHORS
Reema Dedania is with the Department of Psychiatry and
Behavioral Sciences, Vanderbilt University Medical Center,
Nashville, TN. Gilbert Gonzales is with the Department of
Health Policy, Vanderbilt University School of Medicine,
Nashville.

Correspondence should be sent to Reema Dedania, Department
of Psychiatry and Behavioral Sciences, 1601 23rd Ave South,
Nashville, TN 37212 (e-mail: [email protected]). Reprints can
be ordered at http://www.ajph.org by clicking the
“Reprints” link.
This article was accepted April 21, 2019.
doi: 10.2105/AJPH.2019.305149
Supplement 3, 2019, Vol 109, No. S3 AJPH Dedania and
Gonzales Peer Reviewed Research S221
AJPH RESEARCH
mailto:[email protected]
http://www.ajph.org
exclusionary policies and attitudes toward
immigrants.13 Other research suggests that
some immigrant groups may experience
barriers to medical care,11 but very little re-
search has directly examined access to care for
immigrants living with psychological distress
in the United States.
This study compared access to care and
health services utilization between US-born
and foreign-born US adults by mental health
status. We hypothesized that foreign-born
individuals with moderate or severe psy-
chological distress may be more likely to face
barriers to care compared with US-born in-
dividuals with no psychological distress.
Knowing the patterns in health care access
between these groups across a spectrum

of mental health statuses is important for
informing ongoing efforts to narrow health
disparities between immigrant and native-
born populations in the United States.
METHODS
This study used data from the 2013–2016
National Health Interview Survey (NHIS),
a nationally representative health survey of
the civilian, noninstitutionalized population.
Conducted annually by the National Center
for Health Statistics at the Centers for Disease
Control and Prevention, the NHIS provides
comprehensive data used to monitor the
nation’s health.14 The questionnaire records
basic demographic, health, and disability in-
formation for each household member. A
single random adult in each household is
selected for a detailed interview on more
specific health information, including health
insurance coverage, access to health care, and
health services utilization. We drew our study
sample from the sample adult component of
the 2013–2016 NHIS, which we accessed
through the University of Minnesota’s
Integrated Public Use Microdata Series,
a systematized and publicly available
version of the NHIS.15
We used demographic data from sampled
adults to identify nonelderly US-born and
foreign-born adults in the NHIS. Consistent
with previous research using the NHIS,
US-born adults included all adults born in 1
of the 50 states, the District of Columbia, or

any US territory.16,17 The NHIS considered
adults born outside the United States and its
territories to be foreign-born; they might
include naturalized citizens, legal permanent
residents, refugees, undocumented immi-
grants, and adults on long-term temporary
visas (e.g., students and guest workers). We
restricted the analysis to nonelderly adults
aged 18 to 64 years (n = 104 196) to examine
health care needs in the working-age pop-
ulation. Our final sample included 85 217
US-born adults and 18979 foreign-born adults.
To measure mental health status, we relied
on the K6 scale of Kessler et al.18 for non-
specific psychological distress. The K6 scale is
a 6-item screening instrument widely used to
assess mental illness in epidemiological stud-
ies. The screening instrument asked how
often during the previous 30 days the re-
spondent felt nervous, hopeless, worthless, so
sad that nothing could cheer him or her up,
restless or fidgety, and that everything was an
effort. Using a 24-point scale, we defined
adults scoring 0 to 4 points, 5 to 12 points, and
13 to 24 points as having no psychological
distress (NPD), moderate psychological dis-
tress (MPD), and severe psychological distress
(SPD), respectively.19
Study Outcomes
We compared 5 dimensions of health care
access and health services utilization by im-
migration status and mental health status.

Three measures of barriers to care due to cost
were unmet medical care, unmet prescription
medications, and unmet mental health care,
all in the prior year. We also included 2
measures that assessed barriers to routine care:
having no usual source of medical care that
included a doctor’s office, a clinic, or health
center, and reporting multiple emergency
room (ER) visits in the prior year (which may
be a source of care when an individual lacks a
regular primary care provider). Of note, all
measures analyzed in this study were self-
reported, but these measures are regularly
used to monitor access to health care in the
United States.14
Statistical Analysis
We used descriptive statistics to charac-
terize the study sample and to compare the
differences between US-born and foreign-
born individuals by mental health status. We
then estimated multivariable logistic re-
gression models comparing each outcome
across 6 groups: US-born with no psycho-
logical distress, US-born with MPD,
US-born with SPD, foreign-born with no
psychological distress, foreign-born with
MPD, and foreign-born with SPD; US-born
adults with no psychological distress served as
the reference group. All models adjusted for
variables associated with health care access,
including gender, age category (18–25, 26–
34, 35–49, and 50–64 years), race/ethnicity
(non-Hispanic White, non-Hispanic Black,

non-Hispanic other races, Hispanic), educa-
tional attainment (less than high school, high
school, some college, college graduate), re-
lationship status (married, divorced or sepa-
rated, widowed, never married), household
income relative to the US Census Bureau’s
poverty guidelines (£ 100%, 100%–199%,
200%–399%, or ‡ 400% of federal poverty
guidelines), health insurance status, self-rated
health status (excellent, very good, good,
poor or fair), number of chronic conditions
(including cancer, hypertension, coronary
heart disease, stroke, chronic obstructive
pulmonary disease, asthma, diabetes, arthritis,
hepatitis, and weak or failing kidneys), US
Census region, and survey year. Follow-up
regression models included interactions be-
tween immigration and mental health status
to determine whether foreign-born adults
were more or less likely to experience barriers
to care compared with US-born adults of the
same mental health status. We conducted
analyses in Stata version 15 (StataCorp LP,
College Station, TX) using survey weights
and the SVY command to adjust standard
errors for the complex survey design of the
NHIS and to generate nationally represen-
tative estimates.20 Results from all logistic
regression models are presented as adjusted
prevalence ratios with 95% confidence in-
tervals. We calculated prevalence ratios using
postestimation predictions at the mean value
for each covariate with the MARGINS
command in Stata. Hypothesis tests compared
the value of each prevalence ratio to 1 using
adjusted Wald tests to reflect the complex

survey design. We also estimated prevalence
ratios for models with interactions using
predicted probabilities for all 6 possible
combinations between immigration (foreign-
born and US-born) and mental health status
(NPD, MPD, and SPD) based on post-
estimation predictions at the mean value for
each covariate.
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S222 Research Peer Reviewed Dedania and Gonzales AJPH
Supplement 3, 2019, Vol 109, No. S3
RESULTS
Table 1 presents characteristics of non-
elderly adults in the United States by
immigration and mental health status. Ap-
proximately 18.1% and 4.1% of US-born
adults reported moderate or severe psycho-
logical distress, respectively. US-born adults
with MPD or SPD were more likely to be
female, divorced or separated, never married,
in low-income households, unemployed,
uninsured, report poor or fair health, and have
multiple chronic conditions compared with
US-born adults with NPD. Age distributions
and racial/ethnic composition across mental
health categories were relatively similar for
US-born adults. About 15.4% and 2.7% of
foreign-born adults reported symptoms of
moderate or severe psychological distress,
respectively. Foreign-born adults with MPD

or SPD were more likely to be female,
Hispanic, divorced or separated, and from
lower levels of educational attainment and
family incomes. Foreign-born adults with
MPD or SPD were also more likely to report
poor or fair self-rated health and multiple
chronic conditions compared with foreign-
born adults with no psychological distress.
Compared with their US-born counterparts,
foreign-born adults were more likely to be
racially and ethnically diverse, married, un-
insured, and to have no chronic condition
diagnoses. Foreign-born adults were also
more likely to have lower education levels
and to reside in low-income households
compared with US-born adults.
Table 2 presents prevalence estimates and
logistic regression results on barriers to care
by immigration and mental health status. On
the basis of unadjusted prevalence estimates,
US-born and foreign-born adults with MPD
or SPD were significantly more likely to have
no usual source of care, multiple ER visits, and
unmet medical care, mental health care, and
prescription medication needs due to cost
compared with US-born adults with no psy-
chological distress. There were no unadjusted
differences inunmet health careneeds between
US-born and foreign-born adults with NPD.
However,comparedwithUS-bornadultswith
NPD, foreign-born adults with NPD were
more likely to have no usual source of care
and less likely to have multiple ER visits.
Table 2 also presents results from multi-

variable logistic regression models that
compared access to care by immigration and
mental health status categories, with US-born
adults with NPD used as the reference group.
After we controlled for sociodemographic
characteristics, US-born adults with moderate
or severe psychological distress were more
likely to have no usual source of care, multiple
ER visits, and unmet medical, mental, and
pharmaceutical care due to cost. After we
controlled for sociodemographic character-
istics, foreign-born adults with NPD were
more likely to have no usual source of care
and less likely to have multiple ER visits and
unmet medical, prescription, or medication
needs due to cost than their US-born
counterparts with NPD. Finally, foreign-
born adults with MPD or SPD were more
likely to have unmet medical care needs,
unmet mental health care needs, and unmet
prescription medication needs compared with
US-born adults with NPD. After we con-
trolled for sociodemographic characteristics,
foreign-born adults with MPD were more
likely to have no usual source of care, and
foreign-born adults with SPD were more
likely to have multiple ER visits compared
with US-born adults with NPD.
Table 3 presents regression adjusted results
on barriers to care with interactions between
immigration and mental health status.
Overall, compared with US-born adults,
foreign-born adults were less likely to report
multiple ER visits and unmet medical care,

mental health care, and prescription medi-
cations due to cost. Foreign-born adults with
NPD and MPD, however, were more likely
to have no usual source of care compared with
their US-born counterparts with NPD and
MPD.
DISCUSSION
The size of the US immigrant population
has increased over time and shows no signs
of abating: the number of foreign-born in-
dividuals in the United States has more than
quadrupled since 1965 and is expected to
reach 78 million by 2065.21 Understanding
the dynamics of immigrant health will help
elucidate the effects on health patterns of both
departing and receiving countries, including
the overall health of the United States.21,22
This analysis complements recent studies in
the immigrant mental health literature that
examined disparities in utilization between
US-born and foreign-born populations. We
found that both US-born and foreign-born
adults with psychological distress experience
wide barriers in care, particularly financial-
related barriers to medical, mental health, and
pharmaceutical care. Previous research has
suggested that immigration status is a de-
terrent to mental health utilization in the
United States. For example, prior studies have
noted that immigrants are significantly less
likely to take prescription drugs and that
having no usual source of care is a major

contributing factor for disparities between
US-born and foreign-born groups’ utilization
rates.23 Conversely, our research suggests
that individuals with psychological distress
living in the United States have unmet health
needs—including the ability to afford pre-
scription drugs—irrespective of immigration
status. Furthermore, in our study, foreign-
born adults with NPD and MPD were much
less likely to have a usual source of care
compared with their US-born counterparts
with NPD and MPD, respectively. These
findings may be explained, in part, by a
growing literature that suggests that it is not
nativity per se that accounts for differences in
immigrants’ health utilization but that the
differences may be rooted in contextual and
interpersonal circumstances among these
groups, such as social support, community
cohesion, or perceived discrimination.23,24
Health care cost was a major barrier to care
for both US-born and foreign-born adults
with psychological distress. More research
should identify best practices for improving
access to routine and affordable medical care
for adults living with psychological distress.
Policymakers should prioritize the develop-
ment of more affordable interventions that
destigmatize treatment of mental illness. An
emphasis on integrated care models and
partnerships between primary care providers
and psychiatrists for both immigrants and
US-born adults, for example, would nor-
malize the screening process of mental illness
and create additional access points to target

those in need. Heightened attention to
mental health prevention services (such as
depression and suicide screening) in primary
care offices or emotional resilience training
in schools may strengthen protective factors
and allow for the early identification and
treatment of mental illness. Similarly,
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TABLE 1—Descriptive Statistics of Nonelderly Adults, by
Mental Health and Immigration Status: National Health
Interview Survey, United
States, 2013–2016
US-Born Foreign-Born
No Psychological Distress, No.
or Weighted %
Moderate Psychological
Distress, No. or Weighted %
Severe Psychological
No Psychological Distress, No.
or Weighted %
Moderate Psychological

Severe Psychological Distress,
No. or Weighted %
Sample size 62 628 15 785 3739 14 783 2926 567
Weighted % 77.8 18.1 4.1 82.0 15.4 2.7
Gender
Male 50.6 43.6 41.0 51.1 43.4 39.2
Female 49.4 56.5 59.0 48.9 56.6 60.9
Age, y
18–25 18.9 20.8 16.0 10.7 12.4 7.0
26–34 19.0 20.0 16.8 22.4 19.7 16.5
35–49 28.8 28.9 28.9 40.4 39.3 40.5
50–64 33.2 30.3 38.3 26.5 28.6 36.1
Race/ethnicity
Non-Hispanic White 73.9 72.3 71.2 17.0 19.3 15.4
Non-Hispanic Black 13.2 14.2 13.7 8.9 7.9 7.6
Hispanic 10.0 10.5 11.5 47.7 50.8 64.6
Non-Hispanic other 3.0 3.0 3.7 26.3 22.0 12.3
Relationship status

Married 52.8 40.2 32.7 66.6 58.1 52.1
Divorced/separated 12.5 17.9 26.9 9.9 14.6 22.8
Widowed 1.5 2.5 3.8 1.2 2.1 3.1
Never married 33.1 39.4 36.5 22.2 25.1 22.1
Missing data 0.2 0.1 0.2 0.2 0.1 0.0
Educational
attainment
< high school 7.3 11.2 21.3 24.6 29.8 40.7
High school
graduate
24.3 26.9 32.3 21.0 20.6 21.3
Some college 34.4 37.8 36.5 19.9 22.1 18.7
‡ bachelor’s degree 33.8 23.8 9.6 33.7 26.7 17.7
Missing data 0.2 0.3 0.4 0.9 0.7 1.7
Family income relative to poverty
£ 100% FPG 9.7 18.3 33.1 16.2 22.2 36.0
100%–199% FPG 13.3 20.6 27.0 22.2 27.0 28.4
200%–399% FPG 26.6 27.7 21.1 25.6 24.7 19.0

‡ 400% FPG 43.5 28.2 14.3 28.5 20.3 10.4
Missing data 7.1 5.1 4.6 7.5 5.8 6.2
Health insurance status
Insured 88.5 83.9 79.9 72.2 67.8 66.0
Uninsured 10.9 15.5 19.6 27.4 31.5 33.2
Missing data 0.6 0.7 0.5 0.5 0.7 0.8
Health status
Excellent 34.9 19.2 7.8 35.9 20.4 15.1
Very good 35.5 29.3 14.6 31.4 25.7 14.1
Good 22.9 30.2 26.4 25.7 36.0 26.9
Poor/fair 6.7 21.3 51.2 7.1 17.9 43.9
Missing data 0.0 0.1 0.1 0.0 0.1 0.0
No. of chronic conditionsa
0 58.9 45.2 26.7 71.4 57.3 40.2
1 25.0 26.2 25.8 19.6 24.9 26.9
‡ 2 15.6 27.5 45.8 8.4 16.8 31.9
Missing data 0.4 1.1 1.7 0.6 1.0 1.0
Note. FPG = federal poverty guidelines (from US Census). Data
are from the 2013–2016 National Health Interview Survey,

adults aged 18–64 years.
aChronic conditions include cancer, hypertension, coronary
heart disease, stroke, chronic obstructive pulmonary disease,
asthma, diabetes, arthritis, hepatitis,
and weak or failing kidneys.
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community-based programs that improve
mental health literacy and promote help
seeking at the onset of symptoms can lead to
early treatment and reduce the chance of
subsequent episodes. For example, we rec-
ommend subsidizing cognitive behavior
therapy as an early intervention method to
prevent posttraumatic stress disorder for in-
dividuals at heightened risk for experiencing
trauma.
Our research also suggests that both
US-born and foreign-born adults with SPD
were more likely to utilize ER services, even
after we controlled for sociodemographic
characteristics. Because health care costs
prevent US-born and foreign-born adults
from receiving necessary medical care, re-
ducing costs toprimary careand mental health
services may also reduce the increased utili-
zation of ERs, which tend to be more ex-
pensive visits. Policymakers and health care
administrators should invest in programs that

use ER visits as an opportunity to employ
care-coordination models consisting of so-
cial services, mental health referrals, and
pharmacist-conducted patient education.
Investing in case managers who proactively
identify patients that frequent the ER but
have chronic and low-acuity mental health
conditions or psychological distress should
connect patients with available community
providers to ensure longitudinal care.
Limitations
A limitation to using the NHIS is that all
responses were self-reported, which can lead
to response and recall bias when describing
access to care. However, the health care access
outcomes we examined are commonly used
to monitor access to care in the United
States.14 Additionally, reporting immigration
status may be limited by selection bias. Prior
research has explored different types of se-
lection, including the “healthy immigrant
effect” or “immigrant paradox” that may
account for better health in immigrant pop-
ulations compared with native-born pop-
ulations.25,26 Experiences of “double
discrimination”—that is, prejudicial treat-
ment based on a history of psychological
distress and race/ethnicity—may prevent
some foreign-born individuals with psycho-
logical distress from participating in the
NHIS. Furthermore, for immigrants who are
undocumented, fear of deportation or legal

repercussions may also discourage participa-
tion in a formal research study. Moreover,
the potential for reverse causality is not
negligible, given the overlap between out-
comes studied (the past year) and exposure of
mental health status (the last 30 days). On-
going longitudinal data would have allowed
for a larger and more detailed examination
of the relationship between psychological
distress and health care access.
Another consideration when interpreting
our results is the fact that the K6 is a screening
tool, not a diagnostic instrument based on
criteria from the Diagnostic and Statistical
Manual of Mental Disorders. As a result, our
psychological outcomes are self-reported
data and not clinical diagnoses. Furthermore,
research on the K6’s sensitivity to change
with culturally diverse groups is needed. In a
study that examined over 1000 articles uti-
lizing the K6 scale, there was inconsistent
evidence for its cultural appropriateness in
TABLE 2—Adjusted and Unadjusted Prevalence Ratios of
Barriers to Care, by Immigration and Mental Health Status:
National Health Interview
Survey, United States, 2013–2016
No Usual Source of Care Multiple ER Visits Unmet Medical
Care Due to Cost
Unmet Mental Health
Care Due to Cost
Unmet Prescription Medications
Due to Cost

Unadjusted
Prevalence, %
Adjusted
PR (95% CI)
Unadjusted
Prevalence, %
Adjusted
PR (95% CI)
Unadjusted
Prevalence, %
Adjusted
PR (95% CI)
Unadjusted
Prevalence, %
Adjusted
PR (95% CI)
Unadjusted
Prevalence, %
Adjusted
PR (95% CI)
US-born
No psychological
distress

14.2 1 (Ref) 4.6 1 (Ref) 5.1 1 (Ref) 0.8 1 (Ref) 4.5 1 (Ref)
Moderate
psychological
distress
16.7 1.17 (1.09, 1.22) 13.7 1.80 (1.65, 1.95) 15.0 2.06 (1.90,
2.23) 6.0 5.43 (4.65, 6.21) 16.3 2.43 (2.24, 2.61)
Severe
psychological
distress
15.8 1.21 (1.05, 1.36) 28.6 2.63 (2.32, 2.95) 26.5 2.62 (2.34,
2.91) 20.8 16.27 (13.65, 18.87) 33.1 3.64 (3.25, 4.03)
Foreign-born
No psychological
distress
23.7 1.25 (1.16, 1.35) 2.6 0.61 (0.52, 0.71) 5.3 0.84 (0.74, 0.94)
0.7 0.81 (0.57, 1.06) 4.4 0.78 (0.68, 0.88)
Moderate
psychological
distress

24.8 1.38 (1.20, 1.55) 7.0 1.07 (0.86, 1.28) 14.3 1.75 (1.48,
2.03) 3.1 2.77 (1.94, 3.60) 12.9 1.64 (1.36, 1.93)
Severe
psychological
distress
20.7 1.23 (0.91, 1.55) 19.5 2.18 (1.56, 2.81) 24.0 2.55 (1.90,
3.20) 13.2 10.35 (6.07, 14.64) 30.7 3.44 (2.50, 4.38)
Note. CI = confidence interval; ER = emergency room; PR =
prevalence ratio. Data are from the 2013–2016 National Health
Interview Survey, adults aged 18–64
years. Adjusted prevalence ratios are from logistic regression
models controlling for gender, age category, race/ethnicity,
educational attainment, marital
status, household income relative to poverty, health insurance
status, self-rated health status, no. of chronic conditions, US
Census region, and survey year.
Sampling weights were used when estimating prevalence and
adjusted prevalence ratios.
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clinic settings.27 The lower prevalence of
MSD and SPD reported by our foreign-born
respondents may not be representative of each
culturally diverse group and may inaccurately
deflate this heterogonous group’s level of

psychological distress. Caution should be
exercised when interpreting K6 scores, and
further research would benefit from the
formulation of a psychological distress con-
struct that includes culturally andlinguistically
diverse clients. Similarly, caution should also
be exercised when generalizing the experi-
ence of all foreign-born adults, as aggregating
immigrants into a single group may conceal
variability within subgroups.28
Another limitation to our analysis was a
relatively small sample size of foreign-born
adults compared with US-born adults. Be-
cause of the small number of foreign-born
adults with severe psychological distress (2.7%
of all foreign-born adults), we were reluctant
to explore additional subgroup analysis such as
method and duration of entry into the United
States, or global region of birth. Furthermore,
we were unable to stratify our results of
immigrants on the basis of elective versus
forced migration because this information was
not collected. Because displaced persons and
refugees are at higher risk for mental health
disorders, our results may be biased to the
extent that immigrants from this subset may
be missing in the analysis.
Another marginalized group that was ex-
cluded is patients within the criminal justice
system, including jails, prisons, and probation
and parole settings, which are known to have
an overrepresentation of mental illness.29–33

One recent meta-analysis that evaluated 28
studies focusing on mental illness in US prisons
found that the range of prevalence estimates
for particular disorders was much greater in
prisons than in community samples.34 Un-
fortunately, this key cohort, which is more
representative of the total population with
mental illness, was excluded from our analysis.
Other research should focus on how health
outcomes vary among US- and foreign-born
individuals within the prison and homeless
populations to allow for a more representative
sample of the mentally ill population.
Finally, because of the cross-sectional
nature of this study, we can establish corre-
lations but not pinpoint the causal mecha-
nisms underlying the health care disparities
for US-born and foreign-born groups.
Unobserved variables—such as experiences
of discrimination in employment or health
care settings—are missing from our analy-
sis and may explain the differences found
in this study. Relatedly, the NHIS does
not ascertain identity-specific reasons for
barriers to care (e.g., care denied because of
immigration status). Therefore, we cannot
definitely establish the link between dis-
crimination and barriers to care measured
here, but ongoing research can help fill this
research gap.
Conclusions
This study found substantial barriers to care

for US-born and foreign-born adults living
TABLE 3—Adjusted Prevalence Ratios of Barriers to Care,
With Interactions Between Immigration and Mental Health
Status: National Health
Interview Survey, United States, 2013–2016
No Usual Source of Care,
Adjusted PR (95% CI)
Multiple ER Visits,
Adjusted PR (95% CI)
Unmet Medical Care Due to
Cost, Adjusted PR (95% CI)
Unmet Mental Health Care Due
to Cost, Adjusted PR (95% CI)
Unmet Prescription Medications
Due to Cost, Adjusted PR (95% CI)
Immigration status
US-born (Ref) 1 1 1 1 1
Foreign-born 1.23 (1.14, 1.32) 0.62 (0.54, 0.70) 0.85 (0.76,
0.94) 0.74 (0.55, 0.93) 0.77 (0.68, 0.86)
Mental health status
No psychological
distress (NPD; Ref)
1 1 1 1 1

Moderate
psychological distress
(MPD)
1.16 (1.02, 1.29) 2.78 (2.46, 3.11) 2.70 (2.42, 2.97) 15.58
(13.09, 18.06) 3.77 (3.37, 4.16)
Severe psychological
distress (SPD)
1.16 (1.09, 1.23) 1.79 (1.65, 1.93) 2.07 (1.92, 2.22) 4.99 (4.30,
5.67) 2.36 (2.20, 2.53)
Immigration status ·
mental health status
Foreign-born with NPD
vs US-born with NPD
1.25 (1.16, 1.35) 0.61 (0.52, 0.71) 0.84 (0.74, 0.94) 0.81 (0.57,
1.06) 0.78 (0.68, 0.88)
Foreign-born with
MPD vs US-born with
MPD
1.18 (1.01, 1.34) 0.60 (0.47, 0.72) 0.85 (0.71, 0.99) 0.51 (0.37,
0.66) 0.68 (0.56, 0.80)

Foreign-born with SPD
vs US-born with SPD
1.02 (0.72, 1.31) 0.83 (0.59, 1.07) 0.97 (0.72, 1.23) 0.64 (0.38,
0.90) 0.95 (0.68, 1.21)
Note. CI = confidence interval; ER = emergency room; PR =
prevalence ratio. Data are from the 2013–2016 National Health
Interview Survey, adults aged 18–64
years. Adjusted prevalence ratios are from logistic regression
models controlling for gender, age category, race/ethnicity,
educational attainment, marital
status, household income relative to poverty, health insurance
status, self-rated health status, no. of chronic conditions, US
Census region, and survey year.
Sampling weights were used when estimating adjusted
prevalence ratios.
AJPH RESEARCH
with psychological distress. Our results
demonstrate a need for the development of
treatment interventions that target adults
living with psychological distress regardless of
immigration status. We urge public health
practitioners to continue to prioritize in-
dividuals living with psychological distress as
a vulnerable and marginalized population.
Additionally, more work is needed to in-
vestigate the specific biopsychosocial

components that are protective against psy-
chopathology, as well as the risk factors for
psychiatric morbidity for individuals with
psychological distress. High-quality, afford-
able medical and mental health care for the
nation’s heterogeneous population will be
achieved only if the health care and policy
arenas jointly prioritize this endeavor.
CONTRIBUTORS
R. Dedania led the idea formulation and overall direction
and planning of the article, as well as its data analysis and
drafting. G. Gonzales assisted with the statistical analysis
and interpretation of the results and participated in
the writing and editing of the article as well as overall
supervision. Both authors provided critical feedback;
participated in the research, analysis, and writing of the
article; and approved the final version to be published.
CONFLICTS OF INTEREST
No competing financial interests exist for either author.
HUMAN PARTICIPANT PROTECTION
This study was deemed exempt from review because
de-identified data were analyzed from secondary sources.
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