By Steven P. Wallace

Immigrants helped to build the United States, and they continue to contribute to its economic and cultural vitality. Our nation’s immigrant population deserves better than the health disparities they now face as they age in their adopted country.

In the overall population of the United States, older adults in general are less diverse, but immigrants age 65 and older are more diverse: 60 percent of older immigrants are from racial and ethnic minority groups, compared to only 20 percent of the total older population being persons of color. In contrast, the non-elderly population is 38 percent persons of color, according to the 2010 American Community Survey (ACS) of the U.S. Census.

Patterns of immigration to the United States have changed dramatically over the past century, and we are now seeing the effect of those changes. In 1970, 79 percent of the 3 million immigrants, ages 65 and older, in the United States were from Europe—a legacy of pre-World War I immigration patterns and restrictive immigration policy. The most common country of birth was Italy. By 2010, the ACS shows that fewer than 30 percent of older immigrants were born in Europe, and 32 percent were born in Latin America and the Caribbean. Older adults born in Asia also constitute a large share (about a quarter) of older immigrants.

As a result of these shifts, health equity concerns are of particular relevance to older immigrants.

Health Inequity and the ‘Immigrant Paradox’

Health inequity is the result of avoidable differences between populations; these stem from a pattern of health determinants, outcomes and resources associated with broader social inequities. As described in my chapter in Prohaska and colleague’s Public Health for an Aging Society (Baltimore, Md.: John Hopkins University Press, 2012), when patterns of social exclusion, blocked opportunities or unequal returns on effort are common to a population, the resulting differences in health status and healthcare are inequitable.

Health equity may not at first be an obvious concern for older immigrants because of what health researchers call the “immigrant paradox.” Despite having levels of income, education, occupation and living circumstances normally associated with below average health, immigrants experience better mortality outcomes than their U.S.-born peers. This is true for immigrants from every part of the world. Most research shows, however, that the health advantage of immigrants declines over time, suggesting that the living situations immigrants face erode the “health capital” that they bring.

The exact mechanisms are not fully understood, but the decline is likely a result partly of structural conditions: stress from uncertainty about immigration status (regardless of actual status); discrimination exacerbated by the highly publicized politicization of immigration policy; living and working conditions that promote poor diets, unhealthy behaviors such as binge drinking and limited physical activity; and poor access to healthcare. Then there are cultural issues, such as conflict with children and grand-children and increased social isolation, also called acculturative stress.

When older immigrants are people of color, they face intersecting lines of oppression, and socially and politically created differences in power and privilege that lead to differences in access to healthcare and the conditions necessary for healthy aging. While we are a nation of immigrants, the United States has a long history of discrimination and exploitation of its immigrant populations.

Immigration Patterns Drive Health Disparities

Many people tend to lump immigrants into a single category: people who were “born abroad.” But the age at which immigrants arrive in the U.S. matters and influences health disparities in this population at large.

Most immigrants to America arrive as young adults and become elderly while living here. They typically come for economic opportunities and frequently start families after they arrive. If they remain in the United States for more than 10 years, they will most likely remain and retire here after working for 30 to 40 years and raising families. They are usually less educated; onethird of these older immigrants did not complete high school compared to one-fifth of U.S.-born elders. Older immigrants who arrived as younger adults often had careers in low-wage jobs with few benefits, lived in low-income neighborhoods and had limited access to medical care. Nonetheless, almost all were employed and earned Medicare.

The other group is adults ages 65 and older living in the United States who were born abroad and came here at age 50 or older. This group accounts for more than one-quarter of older immigrants. While many of them also worked and cared for families after their arrival, they have had less exposure to the United States and its healthcare institutions and public programs. Thus, it is more difficult for this group to interact with such institutions. In addition, they are twice as likely as those arriving at younger ages to be linguistically isolated (40 percent versus 23 percent)—meaning no adult in their household speaks English very well.

This older cohort also has lower educational levels and higher poverty rates than the group of immigrant elders who arrived earlier in life. One-fifth of this group does not qualify for Medicare, adding to their precarious relationship to the medical care system.

Break Down Barriers, Support Diversity

As we work to reduce health inequalities in our country, it is important to remember that while linguistic and cultural competence are crucial for older immigrants, broader societal patterns that disadvantage elders of color and immigrants create conditions making it difficult for them to have a healthy old age.

We need to create supportive institutions and laws. Service providers can offer tailored programs in multiple languages, including immigration counseling and information about American culture (not to change immigrant elders, but to help them to be better equipped to deal with children and grandchildren raised here). And at a broader level, immigrant elders will be emotionally and physically healthier when they and their families make a living wage and are not worried about being divided by deportations.

All of our programs and policies need to celebrate and support our nation’s diversity—for it is one of our greatest strengths.

Steven P. Wallace, Ph.D., is the chair and professor of the Department of Community Health Sciences at the UCLA Fielding School of Public Health, and associate director at the UCLA Center for Health Policy Research, Los Angeles, Calif.

Editor’s Note: This article appears in the November/December 2012, issue of Aging Today, ASA’s bi-monthly newspaper covering issues in aging research, practice and policy nationwide. ASA members receive Aging Today as a member benefit; non-members may purchase subscriptions at our online store.

Photo: istockphoto/azndc