How welfare reform act affects elderly immigrants' health and healthcare service utilization: Comparisons before and after welfare reform

Background: The intended result of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (Public Law 104-193: PRWORA) was to conserve public funds while addressing welfare deficits. To be eligible for public assistance 'Public Law 104-193' and 'Affidavit of Support Under Section 213A of I-864' require elderly immigrants (a) becoming U.S. citizens or (b) completing 40 quarters (i.e., 10 years' worth) of work requirement unless they live in a state which provides state-funded assistance.;Some factors related to elderly immigrants raise some concerns about elderly immigrants' health. The factors may include that (1) most commonly, elderly immigrants enter the United States at 60–79 years of age through the family reunification program at the invitation of their naturalized adult children, implying that these immigrants have little or no U.S. work history and that they are more likely than their U.S.-born counterparts to live in poverty (Leach, 2009); (2) elderly immigrants, in particular, those from non-English speaking countries, are limited in learning a second language at their later age to pass the citizenship test which asks their listening, writing, and speaking ability in English; and (3) they are more likely than their U.S.-born counterparts to rely on Medicaid.;Objectives: By comparing two different U.S. welfare regimes (i.e., the pre-PRWORA era and post-PRWORA era), the present study examined the impact of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (Public Law 104-193: PRWORA) (1) on elderly immigrants' healthcare service utilization by adopting Andersen's Behavioral Model of Health Services Use (Andersen, 1968, 1995, 2008) and (2) on their health by testing "healthy immigrant effect" theories applicable to elderly immigrants in the United States. The study population is defined as immigrants aged 65 or older who were in the United States at the time of the interview.;Methods: To analyze data from the 1993–1996 (for the pre-PRWORA) and 2002–2008 (for the post-PRWORA) National Health Interview Survey collected by the Centers for Disease Control and Prevention, the present study used multilevel random intercept models with logit link function to address violation of independent observations within states with similar adaptation of PRWORA and within a racial/ethnic group sharing similar health beliefs, culture, and language. The multilevel models were estimated by adopting Markov Chain Monte Carlo (MCMC) method in MLwiN 2.20, which allows Bayesian models to be fitted. The MCMC is the best with discrete response models: it has no requirement of normality assumption in making inferences for variance parameters (Browne, 2009). The dependent variables used to test elderly immigrants' healthcare service use behaviors are (1) "doctor visits during the past 2 weeks" as a discretionary behavior and (2) "short-stay hospital use during the past 12 months" as a non-discretionary behavior. To test elderly immigrant's health, the dependent variables are (1) "self-assessed health status" and (2) "activity limitation status due to one or more chronic diseases." They are all binary variables.;Results: Discretionary Healthcare Service Use: During the pre-PRWORA period, only age and health status significantly explained discretionary service use behavior. However, during the post-PRWORA period, education, citizenship, and the length of residence in the U.S. became important indicators in elderly immigrants' discretionary service use behavior. In addition, before the PRWORA, racial/ethnic minority groups' use of discretionary healthcare service use was not significantly different from that of non-Hispanic whites. However, after the PRWORA, all racial/ethnic groups but Cubans were much less likely than non-Hispanic whites to use discretionary healthcare services.;Non-discretionary Healthcare Service Use: Elderly immigrants' health status and age substantially and significantly explained their non-discretionary health service use both before and after PRWORA. However, during the post-PRWORA era, race/ethnicity and health insurance coverage status became significant contributors, in addition to educational achievement level.;Health Status: As Jasso, Massey, and Rosenzweig (2004) postulated, the findings show a 'reversed healthy immigrant effect' before welfare reform: newly arrived immigrants were more likely than immigrants who had lived longer in the United States to report poor health and activity limitation due to chronic disease, with the best perception of good health and the least reports of activity limitation due to chronic disease among those with 15 or more year residents. The opposite pattern in the period after welfare reform was observed: newcomers were more likely than immigrants who had lived longer in the United States to report good health, with the worst perception of poor health and the most reports of activity limitation due to chronic disease among those 5- to 14-year residents. (Abstract shortened by UMI.).