Immigration Status: A Political Determinant of Health
By Kimberly Horner | November 16, 2021
Kimberly Horner is doctoral student at the University of Minnesota Humphrey School of Public Affairs.
While immigration status has been called a “social determinant of health” in recent scholarship, it might be more aptly labeled a “political determinant of health” in the US. Political decisions and policies are directly linked to the health, well-being, and opportunities for the foreign-born, who are overrepresented in frontline jobs and less likely to have access to healthcare, especially when fearful of deportation or risks to future citizenship opportunities.
The COVID-19 pandemic has highlighted existing inequalities in health and health care access in the US. Particular disparities have emerged along racial and ethnic lines, as minority populations have suffered disproportionate COVID-19 cases, hospitalizations, and deaths throughout the pandemic. But while there has been significant speculation about the impact of COVID-19 on immigrant communities, a lack of national level data disaggregated by country of birth has limited research.
While there has been significant speculation about the impact of COVID-19 on immigrant communities, a lack of national level data disaggregated by country of birth has limited research.
Access to Minnesota 2020 death certificates, which includes information about decedents’ country of birth, has allowed for a more nuanced understanding of COVID-19 disparities among immigrant populations. Recently, my colleagues and I at the Minnesota Population Center published a study illustrating the heightened age- and gender-adjusted 2020 COVID-19 mortality rates among foreign-born Minnesota residents as compared to US-born residents. This analysis highlights not only the heightened COVID-19 mortality rates among Minnesota’s immigrant communities, but particularly among foreign-born men, suggesting that efforts to achieve equity in health care, health protection, and vaccine access by public health officials and policymakers have fallen far short.
Unpacking Pandemic Mortality in Minnesota
Initial comparisons of COVID-19 deaths among US-born and foreign-born Minnesotans yielded what appeared to be expected rates of COVID-19 mortality. Approximately 89.5% of 2020 COVID-19 deaths in Minnesota were among US-born residents, and approximately 91.6% of Minnesota residents are US-born.
However, this crude calculation ignores important differences in the demographic make-up of US-born and foreign-born populations in Minnesota. Perhaps most importantly, the foreign-born population of Minnesota includes a higher proportion of younger and working age individuals, while the US-born population includes a higher proportion of older adults.
Studies have shown that COVID-19 is more likely to have serious health consequences for older individuals, as well as for men. When we adjust for population-level differences in age and gender, we find that immigrants experienced a COVID-19 mortality rate twice that of US-born Minnesotans: 261.4 vs 129.7 deaths per 100,000.
When we adjust for population-level differences in age and gender, we find that immigrants experienced a COVID-19 mortality rate twice that of US-born Minnesotans.
Adjusted mortality rates were also higher among immigrants within racial categories, with foreign-born Black, White, Latino, and Asian populations suffering higher age-specific COVID-19 mortality rates than respective US-born populations from the same racial groups.
Additional analysis reveals substantial differences in the gendered impact of COVID-19 among US- and foreign-born Minnesotans. Foreign-born men and women died from COVID-19 at younger ages than their US-born counterparts, and within subgroups, a higher proportion of young men died than women.
Age distribution of 2020 Minnesota COVID-19 deaths, by nativity and gender
In 2020, foreign-born women in Minnesota experienced an age-adjusted COVID-19 mortality rate 1.8 times higher than US-born women, but it was foreign-born men who saw the heaviest COVID-19 mortality burden. Foreign-born men experienced an age-adjusted COVID-19 mortality rate 2.2 times higher than US-born men, and 1.5 times higher than foreign-born women.
Crude and age-adjusted 2020 Minnesota COVID-19 mortality, by nativity and gender (per 100,000)
Health Equity Requires Commitment
Addressing these health disparities includes work in at least two areas. In the short term, policymakers must invest in strategies that make COVID-19 relief programs and funds more accessible to immigrant communities. While some cities have created funds specific for local immigrant communities, immigrant households are less likely to access federal grant money and are also less likely to apply for public assistance if they include household members who are not US citizens. Policymakers must address policies that disregard the well-being of immigrant communities either through explicit exclusion (e.g. CARES funding) or by inadequately addressing well-founded fears inhibiting benefit access (e.g. public charge chilling effects).
Policymakers must address policies that disregard the well-being of immigrant communities either through explicit exclusion or by inadequately addressing well-founded fears inhibiting benefit access.
Longer-term, health equity requires prioritizing immigrant communities, starting with better data and investing in trusted community programs. Collecting data regarding immigration status or country of origin is fraught with challenges, as historical and present-day xenophobic rhetoric and policymaking often deter immigrants from accessing services when such information is requested. Nonetheless, understanding the specific challenges and strengths of immigrant communities is critical to creating more equitable health outcomes. Officials must continue listening to and learning from those who are suffering to understand the intersecting barriers that affect immigrant communities. Collaborating with immigrant-serving organizations to better understand and fund needed programs beyond the duration of this crisis will better equip our communities to confront systemic as well as future public health challenges.
Heightened mortality rates among foreign-born Minnesotans, and foreign-born men especially, demonstrate the need for a better understanding of the intersection of policy with economic and social characteristics that put immigrant communities more at risk. While COVID-19 is an acute health crisis, disparities in health care are deeply rooted in this nation’s history. Addressing this reality will require sustained commitment from researchers and policymakers over the long term.