Health Status and Hospital Utilization of

Recent Immigrants to New York City

1
Peter Muenni g, M.D., M.P.H.,
2
and Mari anne C. Fahs, Ph.D., M.P.H.
SophieDavis School of Biomedical Education, City University of New York, New York, New York 10032
Background. This paper examines hospital utiliza-
tion, estimated hospital costs, and mortality rates for
U.S.-born, foreign-born, and Puerto Rican-born per-
sons residing in New York City.
Methods. We conducted a multivariate regression
analysis using New York City neighborhoods as the
unit of analysis. We utilized data from the Statewide
Planning and Research Cooperative System data set
and from the 1997 Housing and Vacancy Survey. We
also examined mortality rates using1990death certif-
icate data and decennial census data.
Resul ts. The foreign-born are much less likely to be
hospitalized for most major categories of illness and
have lower mortality rates than either U.S.-born or
Puerto Rican-born New Yorkers. The life expectancy
at 1 year of age of the foreign-born is 4 years longer
than for U.S.-born persons and 6 years longer than
PuertoRican-born persons. Weestimatethat theover-
all cost of providinghospital-basedcaretotheforeign-
born was $611 million dollars less than the cost of
providing hospital-based care to an equivalent num-
ber of U.S.-born persons in 1996.
Concl usi on. The foreign-born in New York City ap-
pear to be healthier and consume fewer hospital re-
sources than U.S.-born populations. It is possible that
the cost of hospital utilization would be lower still if
the foreign-born population had better access to am-
bulatory and preventive services. 2002 American Health
Foundation and Elsevier Science (USA)
Key Words: immigration and emigration; mortality;
health status; health services accessibility.
INTRODUCTION
I n 1990, al most 34% of New York Ci tys popul ati on
was composed of persons born outsi de of the Uni ted
States or i ts terri tori es [1]. By 1999, the proporti on of
forei gn-born persons resi di ng i n New York Ci ty had
grown to al most 40% [2]. The majori ty of forei gn-born
persons are uni nsured and l ow-i ncome forei gn-born
persons are i nel i gi bl e for publ i cl y funded medi cal care
by l aw, i n part because of an overal l percepti on that
cari ng for i mmi grants i s expensi ve [3,4].
Neverthel ess, good heal th outcomes among forei gn-
born persons have been reported i n the medi cal l i ter-
ature, suggesti ng l ower medi cal uti l i zati on among thi s
popul ati on [5]. Recent i mmi grants were found to have
l ower overal l sel f-reported rates of di sease and ranked
hi gher i n heal th status measurement scal es than ei -
ther U.S.-born persons or i mmi grants who have re-
si ded i n the Uni ted States 10 years or more [6].
Other countri es have reported si mi l ar ndi ngs. For
i nstance, heal th care uti l i zati on rates may be l ower
and l i fe expectancy hi gher among l egal i mmi grants to
Canada than nati ve-born Canadi ans [7].
Studi es i ndi cati ng that i mmi grants are general l y
heal thi er than nati ve-born persons have l ed to the
heal thy mi grant hypothesi s, whi ch purports that i m-
mi grants and other forei gn-born popul ati ons are a sel f-
sel ected heal thy popul ati on, due to the necessi ty of
heal th for undertaki ng strenuous travel . Lower rates
of chroni c di sease i n devel opi ng countri es may contri b-
ute to thi s phenomenon.
Federal l aw l i mi ts el i gi bi l i ty for federal l y funded
medi cal care programs to persons who i mmi grated
pri or to 1996 or who became di sabl ed whi l e resi di ng i n
the Uni ted States [8]. Those who l egal l y i mmi grated
after 1996 may onl y recei ve government benets after
5 years of resi dence i n the Uni ted States, compl i cati ng
access i ssues i n an al ready underi nsured popul ati on
[911]. I f forei gn-born popul ati ons are i ndeed heal thi er
than U.S.-born popul ati ons, i t i s l i kel y that i mmi -
grants consume fewer medi cal resources than U.S.-
born persons. Therefore, nati onal i mmi grant heal th
1
Thi s project was supported by a grant from the Henry Luce
Foundati on and was prepared as part of a study on the economi cs of
i mmi grati on for the I nternati onal Center of Mi grati on, Ethni ci ty and
Ci ti zenshi p at the New School Uni versi ty.
2
To whom correspondence and repri nt requests shoul d be ad-
dressed at Sophi e Davi s School of Bi omedi cal Educati on, Ci ty Uni -
versi ty of New York, 138th Street and Convent Avenue, New York,
NY 10032. E-mai l : petermuenni g@yahoo.com.
Preventi ve Medi ci ne 35, 225231 (2002)
doi :10.1006/pmed.2002.1072
225
0091-7435/02 $35.00
2002 Ameri can Heal th Foundati on and El sevi er Sci ence (USA)
Al l ri ghts reserved.
pol i cywhi ch i s based i n part on fears that i mmi -
grants di sproporti onatel y consume l ocal or nati onal
heal th resources [3,4,10]shoul d be reexami ned i f i m-
mi grants i n fact consume fewer heal th resources than
noni mmi grants.
Thi s i nvesti gati on exami nes the heal th status of
New York Ci tys forei gn-born popul ati ons, thei r pat-
terns of heal th servi ce uti l i zati on, and the cost of pro-
vi di ng hospi tal -based care to thi s popul ati on i n New
York Ci ty. Usi ng a smal l area anal ysi s [12], we under-
take an empi ri cal i nvesti gati on of the determi nants of
hospi tal use among i mmi grants, exami ni ng the rol es
that i ncome, gender, race, ethni ci ty, years of resi dence
i n the Uni ted States, and housi ng condi ti ons pl ay
among forei gn-born and U.S.-born persons. We al so
exami ne whether tradi ti onal ri sk factors for di sease i n
U.S.-born popul ati ons remai n predi ctors of di sease i n
the forei gn-born and esti mate the cost of provi di ng
hospi tal care to i mmi grant popul ati ons.
METHODS
Overview and Denitions
To ascertai n the heal th status of forei gn-born per-
sons resi di ng i n New York Ci ty, we conducted two
di sti nct i nvesti gati ons, one exami ni ng hospi tal i zati on
rates and the other exami ni ng mortal i ty rates. I n the
rst, we exami ned hospi tal i zati on records to determi ne
whether forei gn-born persons are hospi tal i zed at a
hi gher or l ower rate than U.S.-born persons or persons
born i n Puerto Ri co, a U.S. terri tory. I n thi s ecol ogi cal
anal ysi s, we compared hospi tal i zati on rates among 55
nei ghborhoods i n New York Ci ty usi ng mul ti vari abl e
l i near regressi on model s. Usi ng the percentage di ffer-
ence i n hospi tal i zati on rates between U.S.-born and
forei gn-born popul ati ons, we then esti mated the over-
al l di fference i n hospi tal costs between these popul a-
ti ons. Si nce hospi tal rates among the forei gn-born ei -
ther may be attri buted to a superi or heal th status or
reduced access to care, we al so anal yzed mortal i ty data
by country of bi rth usi ng standard demographi c meth-
ods.
Our anal ysi s i ncl uded al l forei gn persons, i ncl udi ng
temporary workers and ful l -ti me resi dents, regardl ess
of whether they were documented or undocumented.
Persons born i n the conti nental Uni ted States and
Hawai i were consi dered U.S.-born and persons born i n
U.S. terri tori es were anal yzed separatel y.
Hospital CareUtilization and Morbidity Analysis
We obtai ned popul ati on data from the 1996 Housi ng
and Vacancy Survey (HVS)a survey of 10,000 house-
hol ds i n New York Ci ty that i s conducted every 3 years
by the Uni ted States Bureau of the Census [13]. The
survey was onl y admi ni stered to persons 18 years and
over and sampl e wei ghts were not avai l abl e for geo-
graphi c regi ons smal l er than sub-borough areas,
nei ghborhoods that consi st of mul ti pl e census tracts.
Overal l and di agnosi s-speci c hospi tal i zati on rates
and charges were cal cul ated usi ng 1996 hospi tal di s-
charge data from the Statewi de Pl anni ng and Research
Cooperati ve System (SPARCS) i n the numerator and
1996 HVS data i n the denomi nator. The SPARCS data
set provi des detai l s of uti l i zati on and heal th status
such as di agnoses, age, race, and genderfor every
nonfederal hospi tal i zati on i n New York State. Mi scl as-
si cati on bi as was mi ni mi zed by exami ni ng onl y major
di agnosti c categori es and total admi ssi ons.
Country of bi rth i s not routi nel y recorded i n most
medi cal records, i ncl udi ng hospi tal i zati on data. By
transl ati ng pati ent addresses i nto the area of resi dence
for each pati ent, we were abl e to anal yze communi ty-
based trends i n hospi tal use and outcomes for forei gn-
born and U.S.-born persons l i vi ng i n speci c geograph-
i cal l y dened regi ons of New York Ci ty.
Usi ng New York Ci tys 55 nei ghborhoods as our uni t
of anal ysi s, we exami ned demographi c and soci oeco-
nomi c covari ates of average hospi tal i zati on rates by
nei ghborhood. We used mul ti vari abl e model s to di sti n-
gui sh the i ndependent effect of the proporti onate pop-
ul ati on l evel of forei gn-born persons resi di ng i n the
nei ghborhood on hospi tal i zati on rates i n that nei gh-
borhood, expl oi ti ng the fact that forei gn-born persons
tend to cl uster i nto ethni c encl aves (demographi cal l y
si mi l ar geographi cal l y conned communi ti es).
Anal yses were conducted usi ng the Stati sti cal Pack-
age for the Soci al Sci ences versi on 9 (SPSS I nc., Chi -
cago, I L). Wi th the excepti on of total househol d i ncome,
al l vari abl es were converted to area-speci c propor-
ti ons by di vi di ng the parameter i n questi on by the total
popul ati on. These proporti ons were then entered i nto
the model as conti nuous vari abl es. Thus, the propor-
ti on of femal es, forei gn-born, bl ack, Asi an, and Lati nos
and persons born i n speci c regi on of the worl d were
tabul ated for each of the 55 nei ghborhoods under study
and i ncl uded as i ndependent vari abl es. The dependent
vari abl e was the rate of hospi tal i zati on per 100 persons,
whi ch i s cal cul ated by di vi di ng the total number of
hospi tal i zati ons i n a nei ghborhood by the total popul a-
ti on of that nei ghborhood. When i ndependent vari abl es
are el i mi nated, the si mpl i ed equati on takes the form
R
f
0.127 0.061 P
f
,
where R
f
i s the hospi tal i zati on rate of forei gn-born
persons and P
f
i s the proporti on of forei gn-born persons
resi di ng i n New York Ci ty.
Si nce the medi an age of a parti cul ar nei ghborhood
masks a wi de vari ati on i n persons of di fferent ages, i t
was necessary to exami ne age effects usi ng a separate
model for four di fferent age groups. The age i nterval s
used i n the anal ysi s of hospi tal i zati on rates were 18 to
226 MUENNI G AND FAHS
25, 25 to 45, 45 to 65, and 65 years and ol der. To
i mprove the stati sti cal power of our anal ysi s, we ana-
l yzed 18- to 45-year-ol ds together i n a base-case anal -
ysi s, i n whi ch mul ti pl e determi nants of heal th were
exami ned.
Mortality Analysis
Mortal i ty rates were cal cul ated usi ng data from the
1990 Uni ted States Census Publ i c Use Mi cro-Sampl e
(PUMS) and 1990 Vi tal Stati sti cs data from the New
York Ci ty Department of Heal th. The error associ ated
wi th smal l er but more recent census sampl es, such as
the Current Popul ati on Survey, was prohi bi ti vel y l arge
for a mortal i ty anal ysi s i n New York Ci ty, and the
l atest year for whi ch mortal i ty data were avai l abl e at
the ti me of the study was 1998.
Age-speci c mortal i ty rates were determi ned by di -
vi di ng the number of deaths among forei gn-born per-
sons, U.S.-born persons, and Puerto Ri cans by the
respecti ve numbers of persons resi di ng i n New York
Ci ty usi ng 1990 New York Ci ty Department of Heal th
Vi tal Stati sti cs Data and the 1990 PUMS from the
Uni ted States Bureau of the Census. Age-standardi zed
rates were obtai ned usi ng the 1990 New York Ci ty
popul ati on as a standard popul ati on.
Li fe expectancy was cal cul ated usi ng standard de-
mographi c methods [14,15] wi th three excepti ons.
Fi rst, we used a l arge i ni ti al age i nterval because there
were smal l numbers of deaths for persons between the
ages of 1 and 25. Second, l i fe expectancy was cal cul ated
at 1 year of age si nce subjects were born outsi de of the
Uni ted States. Thi rd, we assumed that persons over
the age of 75 woul d have a l i fe expectancy of 11.1 years
(the l i fe expectancy at 75 i n the Uni ted States) regard-
l ess of the country of ori gi n [16].
Cost of Hospitalization
Usi ng total hospi tal charges for each age i nterval , we
esti mated the total hospi tal charges saved for forei gn-
born persons usi ng the formul a:
R
f
R
n

R
i
C
t
,
where R
n
i s the rate of hospi tal i zati on of nati ve-born
persons and C
t
i s the total annual charge for servi ces
reported by New York Ci ty hospi tal s. The val ue for R
f
was determi ned usi ng the si mpl i ed regressi on for-
mul a above and a val ue of 0.35 for P
f
.
We converted charges to costs usi ng cost-to-charge
rati os deri ved from the Heal th Care Fi nanci ng Admi n-
i strati ons Medpar data set [17,18]. Data l i mi tati ons
prevented us from exami ni ng the proporti on of forei gn-
born persons resi di ng i n a nei ghborhood as an i ndepen-
dent predi ctor of hospi tal charges. Therefore, i t was
necessary to assume that per capi ta hospi tal charges
were si mi l ar for U.S.-born and forei gn-born persons,
whi ch woul d not hol d true i f the severi ty of di sease
di ffered between the forei gn-born and U.S.-born per-
sons.
RESULTS
Summary measures of demographi c characteri sti cs
for New York Ci ty resi dents avai l abl e are presented i n
Tabl e 1. Approxi matel y 13% of the persons sampl ed i n
the HVS di d not report thei r country of bi rth.
Hospitalization among 18- to 45-Year-Olds
(Base-CaseAnalysis)
I n New York Ci ty nei ghborhoods, hospi tal i zati on
rates among 18- to 45-year-ol ds vari ed from approxi -
matel y 5.5 hospi tal i zati ons per 100 resi dents per year
(the Upper East Si de i n Manhattan) to 20 hospi tal i za-
ti ons per 100 resi dents per year (Morri sani a i n the
Bronx) i n 1996. Forei gn-born persons were represented
i n al l nei ghborhoods, compri si ng between just over
10% of the popul ati on of the Upper East Si de i n Man-
hattan to just under 80% of the popul ati on of Jackson
Hei ghts i n Queens. Fi gure 1 i l l ustrates the rel ati on-
shi p between the percentage of forei gn-born persons
l i vi ng i n a nei ghborhood (pi e chart) and the hospi tal -
i zati on rate (darker col ored nei ghborhoods have a
hi gher rate of hospi tal i zati on). Of the 27 nei ghbor-
hoods wi th l ower than average hospi tal i zati on rates,
20 had forei gn-born popul ati ons above the mean for
New York Ci ty.
I n uni vari ate anal yses, total househol d i ncome, gen-
der, race, ethni ci ty, country of ori gi n, and overcrowd-
i ng were al l si gni cantl y correl ated wi th hospi tal i za-
ti on rates (see Tabl e 2). I ncreasi ng percentages of
forei gn-born occupants i n a nei ghborhood predi cted
l ower rates of hospi tal i zati on for i nfecti ous di sease,
cancer, ci rcul atory condi ti ons, mental i l l ness, and ner-
vous system condi ti ons (data not shown). Hospi tal i za-
ti on rates for di gesti ve condi ti ons, however, were si m-
TABLE 1
Demographi c Characteri sti cs of New Yorkers
by Pl ace of Bi rth
a
Nati ve-born Forei gn-born New York Ci ty
Medi an age (years) 43 42 43
Medi an i ncome $37,070 $33,500 $34,920
Percentage femal e 56 47 51
Percentage Hi spani c 13 33 26
Percentage Bl ack 36 31 31
Percentage Whi te 63 48 59
Percentage Asi an 2 20 9
a
Does not i ncl ude not reported cases.
Source: Uni ted States Bureau of the Census, 1996 Housi ng and
Vacancy Survey.
227 HEALTH OF I MMI GRANTS
i l ar i n nei ghborhoods wi th hi gh and l ow proporti ons of
forei gn-born persons.
Tabl e 3 l i sts the resul ts of the mul ti vari ate anal yses.
After control l i ng for covari ates, U.S.-born persons and
Puerto Ri can-born persons were more l i kel y to be hos-
pi tal i zed than forei gn-born persons; however, hospi tal -
i zati on rates for Cari bbean persons from non-U.S. ter-
ri tori es were not si gni cantl y l ower than average.
When i ncome, gender, race, and ethni ci ty are not ac-
counted for, the ri sk of hospi tal i zati on for U.S.-born
persons was not stati sti cal l y si gni cant i n the base-
case anal ysi s. Thi s was true i n the subanal ysi s of 18- to
25-year-ol d persons but not i n the 25- to 45-year-ol d
subgroup, suggesti ng that younger forei gn-born per-
sons may be at greater ri sk of hospi tal i zati on than
ol der forei gn-born persons rel ati ve to nati ve-born per-
sons. Control l i ng for Asi an race had l i ttl e i mpact on the
associ ati on between the total number of forei gn-born
persons resi di ng i n a nei ghborhood and the hospi tal -
i zati on rate.
The factors we studi ed expl ai ned approxi matel y 69%
of the vari ati on i n the rate of hospi tal i zati on between
nei ghborhoods, wi th i ncome accounti ng for over 54% of
the hospi tal i zati on rate and the percentage of forei gn-
born persons expl ai ni ng al most 10% of the vari ati on.
Hospitalization among Persons Aged 45 to 65
I n uni vari ate anal yses, the di recti on, magni tude,
and si gni cance of the determi nants of hospi tal i zati on
TABLE 2
Si gni cant Predi ctors of Hospi tal i zati on i n New York Ci ty
Nei ghborhoods for 18- to 45-year-ol ds
Total fami l y i ncome r 0.65 (P 0.001)
Percentage femal e (i ncl udes
hospi tal i zati ons for normal bi rths) r 0.70 (P 0.001)
Percentage Whi te r 0.55 (P 0.01)
Percentage Hi spani c r 0.31 (P 0.01)
Percentage of househol ds wi th 1.5
persons per room r 0.25 (P 0.05)
Percentage of forei gn-born (excl udes
U.S. terri tori es)
18 to 45 years r 0.27 (P 0.05)
25 to 45 years r 0.35 (P 0.05)
FIG. 1. Hospi tal rates and the percentage forei gn-born i n New York Ci ty nei ghborhoods, 1996. (Source: Uni ted States Bureau of Census;
Housi ng and Vacancy Survey, 1996; and the Statewi de Pl anni ng and Research Cooperati ve System, 1996.)
228 MUENNI G AND FAHS
for persons aged 4565 were si mi l ar to those for the 18-
to 25- and 18- to 45-year-ol d groups. When control l i ng
for gender, i ncome, and race i n mul ti vari abl e model s,
the percentage of forei gn-born persons aged 45 to 65
was negati vel y associ ated wi th the rate of hospi tal i za-
ti on ( 0.082; P 0.0001). The ri sk factors we
exami ned accounted for approxi matel y 61% of the fac-
tors l eadi ng to hospi tal i zati on. As i n the base-case
anal ysi s, the percentage of Puerto Ri cans i n a nei gh-
borhood predi cted si gni cantl y hi gher hospi tal i zati on
rates ( 0.13; P 0.001), as di d the percentage of
persons born i n the conti nental Uni ted States (
0.067; P 0.003), when covari ates were i ncl uded i n the
model . After removi ng covari ates, the rel ati onshi p re-
mai ned si gni cant.
Hospitalizations among Persons Aged 65 and Over
There were no si gni cant di fferences i n hospi tal i za-
ti on rates between nei ghborhoods when onl y persons
over the age of 65 were exami ned. Thi s hel d true when
we attempted to control for race, i ncome, and gender
Costs
I n 1996, hospi tal i zati on charges for persons 18 to 45
were approxi matel y 3.5 bi l l i on dol l ars. Forei gn-born
persons may have reduced adjusted hospi tal costs by
$300 mi l l i on dol l ars i n 1996 (95% condence i nterval
$291 mi l l i on to $323 mi l l i on). Unadjusted savi ngs
(charges) were $720 mi l l i on dol l ars.
The di fferenti al i n hospi tal costs between U.S.-born
and forei gn-born hospi tal i zati on patterns of persons i n
the 45- to 65-year age group was greater than i n the 18-
to 45-year age group, amounti ng to $311 mi l l i on (95%
condence i nterval $219 mi l l i on to $382 mi l l i on) on
total charges of $3.2 bi l l i on. Unadjusted savi ngs were
$747 mi l l i on dol l ars. For persons 65 and over, no sav-
i ngs were predi cted. Total predi cted savi ngs i n soci etal
costs from reduced hospi tal i zati ons among the forei gn-
born for persons 18 to 65 years amounted to $611
mi l l i on dol l ars i n 1996.
Mortality Rates
Forei gn-born persons have l ower age-standardi zed
rates of death, a l onger l i fe expectancy, and fewer years
of l i fe l ost to di sease than U.S.-born persons (see Tabl e
4). I n 1990, forei gn-born persons l i ved approxi matel y 4
years l onger than U.S.-born persons and 6 years l onger
than Puerto Ri cans at 1 year of age. The mortal i ty rate
for forei gn-born persons between the ages of 1 and 25
years of age was not si gni cantl y di fferent from rates
reported for U.S.-born persons, however.
Persons born i n terri tori es of the Uni ted States re-
si di ng i n New York Ci ty appear to be at greater ri sk of
death than persons born i n the Uni ted States when al l
age groups are consi dered together. However, after the
age of 45, the ri sk of death i s roughl y comparabl e to
persons born i n the conti nental Uni ted States and Ha-
wai i .
DISCUSSION
Gi ven the l ower hospi tal i zati on and mortal i ty rates
among forei gn-born persons l i vi ng i n New York, the
forei gn-born appear to be i n better heal th than U.S.-
born New Yorkers. Hospi tal i zati on rates for cancer,
ci rcul atory di sorders, mental i l l ness, neurol ogi cal con-
TABLE 3
Determi nants of Hospi tal i zati on Rates for Nei ghborhoods
by Proporti on of Resi dents 1845 Years of Age Who Are
Forei gn-Born, Nati ve-Born, or Born i n Uni ted States Terri -
tori es
Sl ope () P val ue R
2
Model s usi ng onl y the fol l owi ng
vari abl es
Forei gn-born 0.06 0.02* 0.09
Born i n the conti nental Uni ted
States 0.04 0.12* 0.05
Born i n Puerto Ri co 0.37 0.0001* 0.40
Model s control l i ng for i ncome, gender,
race, and ethni ci ty and separatel y
addi ng the fol l owi ng vari abl es
Forei gn-born 0.08 0.0001* 0.69
Control l i ng for Asi an race 0.07 0.001* 0.64
Born i n non-U.S. Cari bbean 0.04 0.06 0.61
Born i n conti nental U.S. 0.61 0.008* 0.63
Born i n Puerto Ri co 0.23 0.0018* 0.65
* Stati sti cal l y si gni cant at P 0.05.
TABLE 4
1990 Mortal i ty Rates per 100,000 Persons
by Country of Bi rth, New York Ci ty
U.S. U.S. terri tory Forei gn
Age (years)
1 to 25 72 123 102
25 to 45 405 694* 197*
45 to 65 1086 1065 533*
65 to 75 2591 2465* 1853*
75 6865 6757* 8800*
ASR
a
965 1054* 841*
Ri sk rati o
1 to 25
b
1.71 1.42
25 to 45 1.71 0.49
45 to 65 0.99 0.49
65 to 75 0.95 0.72
75 0.98 1.28
ASR* 1.08 0.86
Li fe expectancy at
1 year of age
72 69 76
* Stati sti cal l y si gni cant (P 0.05).
a
Age-standardi zed rate usi ng the 1990 New York Ci ty popul ati on
as a standard popul ati on.
b
The ri sk of death for persons born i n Uni ted States terri tori es
and forei gn-born persons rel ati ve to nati ve-born persons.
229 HEALTH OF I MMI GRANTS
di ti ons, and i nfecti ous di sease al l decl i ne as the per-
centage of forei gn-born persons i n a nei ghborhood i n-
creases and thi s trend conti nues unti l at l east age 65.
Despi te l i mi ted access to ambul atory and preventi ve
care servi ces [3,4,911], whi ch may l ead to hi gher ad-
mi ssi on rates [3], hospi tal costs for the forei gn-born
were l ess than among the U.S.-born. Overal l cost sav-
i ngs from reduced hospi tal uti l i zati on amounted to
$611 mi l l i on.
The overal l soci etal savi ngs reect costs associ ated
wi th the producti on and del i very of medi cal products
and servi ces, but do not i ncl ude hospi tal prots. Si nce
federal payors excl ude prots when rei mbursi ng hos-
pi tal s, soci etal costs better reect the scal burden of
hospi tal costs i n the publ i c sector than hospi tal
charges.
The l ower hospi tal i zati on and mortal i ty rates among
forei gn-born groups may i n part be due to sel ecti on
factors among i mmi grant groups, si nce l egal i mmi -
grants must undergo a medi cal exami nati on (to rul e
out excl udabl e condi ti ons, mostl y acti ve i nfecti ous di s-
eases) pri or to entry i nto the Uni ted States, must be
heal thy enough to travel , and may al so come from
countri es wi th l ower rates of chroni c di sease [57,19].
Three di sti nct factors may contri bute to the hi gher
rates of mortal i ty and comparabl e rates of morbi di ty i n
forei gn-born persons over the age of 65 we observed.
Fi rst, forei gn-born persons may experi ence a decl i ne i n
heal th status as they become accul turated and are
exposed to ri sk factors for chroni c di sease, such as a
poor di et, poor housi ng condi ti ons, and cri me. Second,
there are cl ear demographi c di fferences i n the vari ous
age cohorts we studi ed wi th younger persons mostl y
havi ng arri ved from devel opi ng countri es and ol der
persons predomi nantl y havi ng arri ved from Western
Europe, where the rate of chroni c di sease i s general l y
hi gher [20]. Fi nal l y, because younger U.S.-born and
Puerto Ri co-born persons have hi gher mortal i ty rates
than forei gn-born persons, onl y the heal thi est mem-
bers of these two groups l i ve past age 75, resul ti ng i n
comparati vel y l ower mortal i ty rates i n l ater years.
Thi s survi vor effect i s frequentl y seen i n l ongi tudi nal
cohort studi es [21].
There were a number of l i mi tati ons to our study.
Fi rst, i n constructi ng l i fe tabl es, we assumed that l i fe
expectancy after age 75 woul d be si mi l ar across coun-
tri es of bi rth. Thi s assumpti on l i kel y resul ted i n a
sl i ght underesti mate of the l i fe expectancy of persons
born i n Uni ted States terri tori es and a sl i ght overesti -
mate of the l i fe expectancy of forei gn-born persons
because of the survi vor effect.
There i s evi dence that the provi si on of ambul atory
care servi ces reduces hospi tal i zati on rates [3]. Because
the forei gn-born appear to be heal thi er than U.S.-born
persons, the need for ambul atory care servi ces woul d
l i kel y be l ower. Though we were not abl e to esti mate
hospi tal i zati on costs or savi ngs associ ated wi th
forei gn-born popul ati ons for persons under the age of
18 or over the age of 65, i t i s not l i kel y that hospi tal
costs associ ated wi th ei ther age group di ffer greatl y
from U.S.-born persons si nce mortal i ty rates i n both of
these age groups were si mi l ar to U.S.-born persons.
The accuracy of our cost esti mates, however, was al so
l i mi ted by our i nabi l i ty to cal cul ate per capi ta hospi tal
charges by sub-borough area. Gi ven that the forei gn-
born may del ay seeki ng treatment for severe medi cal
condi ti ons l eadi ng to unavoi dabl e hospi tal i zati on, i t i s
possi bl e that the hospi tal charges for those forei gn-
born persons who are actual l y hospi tal i zed are hi gher
than for U.S.-born persons. These di fferences i n per
capi ta costs were not captured.
Fi nal l y, we empl oyed a smal l area anal ysi s, whi ch i s
subject to bi as. For i nstance, i mmi grants tend to l i ve i n
l ower i ncome nei ghborhoods. Nati ve-born persons re-
si di ng i n these nei ghborhoods are l i kel y much l ess
heal thy than forei gn-born persons, but have si mi l ar
i ncomes. The presence of l ow-i ncome nati ve-born per-
sons i n a predomi nantl y forei gn-born nei ghborhood
woul d reduce the magni tude of the observed di fference
i n hospi tal i zati on rates and costs rel ati ve to a noneco-
l ogi cal anal ysi s.
Heal th care i s the thi rd l argest economi c sector i n
New York Ci ty, accounti ng for more than 13% of al l
empl oyment and wages and i s an economi c sector
heavi l y dependent on publ i c funds [22]. The heal th
care sector, l i ke vi rtual l y al l segments of New Yorks
economy, i s dependent on forei gn-born workers that
must be heal thy to be producti ve [3,23]. We were not
abl e to add producti vi ty effects to our economi c anal y-
si s. Were we abl e to, the projected savi ngs may be
hi gher.
Both the HVS, whi ch was used to cal cul ate hospi tal -
i zati on rates, and the 1990 PUMS, whi ch was used to
cal cul ate mortal i ty rates, l i kel y underesti mated the
number of forei gn-born persons (especi al l y undocu-
mented persons), i mpoveri shed persons, and raci al mi -
nori ty groups [24]. We assumed that thi s underesti -
mate was consi stent across sub-borough areas. I f thi s
assumpti on i s correct, undercounti ng woul d have no
effect on the smal l area anal ysi s si nce onl y the propor-
ti on of forei gn-born persons resi di ng i n each sub-
borough area was entered i nto the mul ti pl e regressi on
model s. However, i t i s possi bl e that the mortal i ty rates
among the forei gn-born we observed represent a hi gh
esti mate si nce popul ati on data are used as the denom-
i nator of such rates.
On the other hand, i t i s possi bl e that l ower mortal i ty
rates reect emi grati on of very i l l persons to thei r
country of bi rth. I f severel y i l l persons return to thei r
homel and to di e, thi s mi ght al so l ower the overal l rate
of hospi tal i zati on i n predomi nantl y forei gn-born nei gh-
borhoods.
230 MUENNI G AND FAHS
The majori ty of forei gn-born persons are not el i gi bl e
to recei ve publ i cl y funded ambul atory or preventi ve
medi cal servi ces [3]. Therefore, i t i s l i kel y that some of
the hospi tal i zati ons and deaths counted i n predomi -
nantl y forei gn-born nei ghborhoods were preventabl e.
Our resul ts suggest that the forei gn-born resi di ng i n
New York Ci ty are heal thi er than U.S.-born persons
and are consumi ng fewer heal th system resources.
Arguments that the forei gn-born are overuti l i zi ng
medi cal servi ces and are thus unfai rl y and di spropor-
ti onatel y drai ni ng publ i cl y funded medi cal resources
appear to be unfounded, and l egi sl ati on based on such
arguments shoul d be reexami ned.
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231 HEALTH OF I MMI GRANTS