1. The Chilling Effect: Anti-Immigrant Threat and Insurance Status Cassie Hartzog COEMH Workshop May 13-14, 2010

2. Why Insurance is Important Better health outcomes Greater continuity of care More preventive care More timely care Financial protection Equity

3. Health Insurance Disparities Foreign-born are less likely to have health insurance Less public, private, & employer insurance Especially non-citizen immigrants Employer and employee characteristics are important Immigrants are less likely to work for employers who offer insurance Unexplained gaps remain!

4. Anti-Immigrant Threat 1994 – Proposition 187 Would have denied education and health care to undocumented immigrants 1996 – PRWORA Recent immigrants lost benefits; confusion about the consequences of using benefits 2010 - Arizona

5. Effects of Anti-Immigrant Laws Anecdotal evidence that laws discourage use of public benefits 50% drop in Medi-Cal enrollment in LA following PRWORA Spillover effect – Largest drop among green-card holders, not the undocumented

6. Is There a Chilling Effect? How much variation in the uninsured rate across counties? How much of that variation is due to county composition, how much to county-level characteristics? Does the social environment affect insurance status?

7. Methods and Data Multilevel logistic regression models Dependent variables – uninsured, private insurance, public insurance Level 1: 8,460 non-elderly adults (California Health Interview Survey 2005) Level 2: 55 of California’s 58 counties

8. Measures County-level covariates Pro-Prop. 187 vote (1994) Immigration raid in 2004 Distance to border, unemployment rate Individual-level covariates Age, gender, ethnicity Education, log of family income Employment status & occupation Residency status, LEP, < 5yrs in US

9. Results – No Individual Controls Uninsured Private Public Pro-Prop. 187 vote1.0150.9801.019 (0.004)*(0.005)***(0.005)** Immigration raid1.1270.9481.019 (0.081)(0.126)(0.137) Distance to border0.9501.0061.052 (0.026)*(0.037)(0.035) Percent Unemployed1.0400.8911.123 (0.016)*(0.021)***(0.016)*** Variance component0.027***0.075***0.039*** % of total variance3.43%8.43%8.00% % of variance explained76.92%75.25%86.36% *** p<0.001; ** p<0.01; * p<0.05

10. Adjusting for County Composition UninsuredPrivatePublic Pro-Prop. 187 vote1.0070.9791.018 (0.003)*(0.005)***(0.006)** Immigration raid1.1610.8801.031 (0.079)+(0153)(0.149) Distance to border0.9350.9981.077 (0.024)**(0.042)(0.037)* Percent unemployed1.0140.8911.124 (0.013)(0.020)***(0.017)*** Variance component0.009*0.088***0.052***

11. Adjusting for County Composition UninsuredPrivatePublic Pro-Prop. 187 vote1.0070.9791.018 (0.003)*(0.005)***(0.006)** Immigration raid1.1610.8801.031 (0.079)+(0153)(0.149) Distance to border0.9350.9981.077 (0.024)**(0.042)(0.037)* Percent unemployed1.0140.8911.124 (0.013)(0.020)***(0.017)*** Variance component0.009*0.088***0.052***

12. Individual Level Results UninsuredPrivateUninsuredPrivate Hispanic2.0810.5391.6160.677 (0.148)***(0.106)***(0.147)**(0.103)*** Asian1.5510.7391.4050.835 (0.064)***(0.063)***(0.064)***(0.062)** Other Non-White1.1530.7221.0040.786 (0.119)(0.133)*(0.134)(0.137) Green card1.3050.763 (0.062)***(0.086)** No green card2.2570.447 (0.090)***(0.074)*** Limited English proficiency1.5980.584 (0.059)***(0.078)*** Less than 5 years in US1.2060.931 (0.097)(0.081)

13. Summary There is county variation, and context matters Anti-immigrant attitudes are associated with higher odds of uninsurance, lower odds of private insurance, but higher odds of public insurance Raids increase the odds of uninsurance

14. Future Research Untangle economic and social context Pro-immigrant context – immigrant organizations Other outcomes – access to health care