Paper 201

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ORIGINAL INVESTIGATION

Health Care Access, Use of Services, and Experiences Among Undocumented Mexicans and Other Latinos Alexander N. Ortega, PhD; Hai Fang, PhD; Victor H. Perez, MD, MPH; John A. Rizzo, PhD; Olivia Carter-Pokras, PhD; Steven P. Wallace, PhD; Lillian Gelberg, MD, MSPH

Background: We compared access to health care, use of services, and health care experiences for Mexicans and other Latinos by citizenship and immigrant authoriza- tion status.

Methods: We acquired data from the 2003 California Health Interview Survey, with 42 044 participants rep- resentative of noninstitutionalized households. Partici- pants were differentiated by ethnicity/race, national ori- gin, and citizenship/immigration authorization status. Outcome measures included having a usual source of care, problems in obtaining necessary care, use of physician and emergency department care, and 3 experiences with health care. Multivariate analyses measured the associa- tions of citizenship/immigration authorization status with the outcome measures among foreign-born Mexicans and other Latinos vs their US-born counterparts.

Results: In multivariate analyses, undocumented Mexi- cans had 1.6 fewer physician visits (P � .01); compared with US-born Mexicans; other undocumented Latinos had

2.1 fewer visits (P � .01) compared with their US-born counterparts. Both undocumented groups were less likely to report difficulty obtaining necessary health care than US-born Mexicans (odds ratio, 0.68; P � .01) and other US-born Latinos (odds ratio, 0.40; P � .01), respec- tively. Undocumented Mexicans were less likely to have a usual source of care (odds ratio, 0.70; P � .01) and were more likely to report negative experiences than US- born Mexicans (odds ratio, 1.93; P � .01). Findings were similar for other undocumented Latinos, with the ex- ception of having a usual source of care. Patterns of ac- cess to and use of health care services tended to im- prove with changing legal status.

Conclusion: In this large sample, undocumented Mexi- cans and other undocumented Latinos reported less use of health care services and poorer experiences with care compared with their US-born counterparts, after adjust- ment for confounders in multivariate analyses.

Arch Intern Med. 2007;167(21):2354-2360

I T HAS BEEN ESTIMATED THAT 8.4 million of the 10.3 million un- documented individuals in the United States are Latino, includ- ing 5.9 million from Mexico and

2.5 million from other Latin American countries.1 Undocumented immigrants have been the recent focus of intense policy debate, resulting in the signing of the Bor- der Fence Act in October 2006 and delib- eration of immigration reform by the 110th Congress. One recurrent theme in the de- bate over immigration has been the use of public services, including health care. Pro- ponents of restrictive policies have ar- gued that immigrants overuse services, placing an unreasonable burden on the public.2 , 3 Despite a scarcity of well- designed research into these questions re- garding immigrants, use of resources con- tinues to be a part of the public debate. Furthermore, little empirical informa-

tion is offered in the literature about ex- periences with health care for undocu- mented immigrants.

Although studies have reported on the use of health care services by Mexican and other Latino immigrants,4-6 less is known regarding variations by documentation sta- tus. This is partly due to the challenges of identification and sampling of the undocu- mented population.7 The few studies that have specifically examined the undocu- mented Latino population have used small samples and limited health care mea- sures. These reports have suggested a pat- tern of barriers and limited access to care for undocumented persons.8-11 Using the Los Angeles Family and Neighborhood Study, Goldman et al12 reported that un- documented residents used health ser- vices less and had fewer expenditures than native-born US citizens. However, the au- thors did not examine the undocu-

Author Affiliations: Departments of Health Services (Dr Ortega) and Community Health Sciences (Dr Wallace), School of Public Health, and Departments of Pediatrics (Dr Perez) and Family Medicine (Dr Gelberg), David Geffen School of Medicine, University of California, Los Angeles; Department of Economics, University of California, Davis (Dr Fang); Departments of Preventive Medicine and Economics, Stony Brook University, Stony Brook, New York (Dr Rizzo); and Department of Epidemiology and Biostatistics, College of Health and Human Performance, University of Maryland at College Park (Dr Carter-Pokras).

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mented residents by national origin or ethnicity. Simi- lar results were found regarding health care expenditures in a national sample of US immigrants.13

The California Health Interview Survey (CHIS) pro- vides a significant adult Latino sample representing each category of immigration authorization, including the un- documented. We have analyzed 2003 CHIS data to an- swer the following 3 questions. When considered along- side US-born Latinos and documented Latino immigrants: (1) Do undocumented Mexicans and other undocu- mented Latinos report different patterns of access to care? (2) Do undocumented Mexicans and other undocu- mented Latinos use health services differently? (3) Do undocumented Mexicans and other undocumented Lati- nos report different health care experiences? Given the lack of empirical information on health care access, use of services, and experiences for undocumented Mexi- cans and other undocumented Latinos, the CHIS pro- vides unique and timely data on a large sample of these populations.

METHODS

We used data from the 2003 CHIS and, for emergency depart- ment (ED) visit data only, the 2001 CHIS. The CHIS is a random- digit telephone survey of households drawn from every county in California, with the results stratified to produce sufficient sample sizes for stable estimates of many smaller counties. The 42 044 adult respondents in 2003 were representative of the noninstitutionalized household population in California. The response rate using the American Association for Public Opin- ion Research—RR4 method was 34%, which is consistent with those of general telephone surveys.14,15 A survey of Califor- nia’s undocumented residents found that 94% have a tele- phone, a rate only slightly lower than the overall state rate.16

The CHIS data were collected in English and Spanish. The trans- lation and cultural adaptation process is detailed elsewhere, as are the data collection methods.17,18

MEASUREMENTS

Access is measured using binary measures of whether the par- ticipant has a usual source of health care and indicating whether the participant had problems getting necessary health care in the past 12 months. We also measured whether the partici- pant had health insurance (insured or uninsured), a well- recognized determinant of access.19

Measures of use of health care services include the number of physician visits during the previous 12 months and binary mea- sures indicating whether the participant had at least 1 physician visit for his or her own care in the past 12 months and whether the participant had at least 1 ED visit during the past year.

Health care experiences are measured by (1) a binary mea- sure indicating whether the participant had a hard time un- derstanding his or her physician during the last visit; (2) a bi- nary measure indicating whether the participant believed he or she would have received better care if he or she were a mem- ber of a different racial or ethnic group; and (3) a measure in- dicating the participant’s global rating of his or her health care during the past year, on a scale from 0 (worst) to 10 (best).

Race, Ethnicity, and Origin

Participants were asked whether they were Hispanic or Latino and whether they were part of 1 or more of the census-

designated racial groups. If they answered yes to more than 1 category, they were asked with which group they most iden- tify. All those who answered that they were Hispanic or Latino were asked about their national origin (eg, Mexican).

Immigrant Authorization Categories and Citizenship

All participants were asked about their country of birth. If not born in the United States, then citizenship status was deter- mined by asking, “Are you a citizen of the United States?” If the response was no, they were asked, “Are you a permanent resident with a green card [permanent residence authoriza- tion]?” Using these questions, we created the following 4 Mexi- can groups: US-born citizens, naturalized US citizens, Mexican- born immigrants with a green card, and Mexican-born undocumented immigrants. Four comparable categories were created for Latinos not of Mexican origin (ie, “other Lati- nos”). Other Latinos included individuals of any other Latino origin in the sample. We also included US-born non-Latino white subjects in the analyses.

Of the noncitizen Mexican immigrants without a green card, 93% are estimated to be undocumented.20 The remainder con- sisted of temporary workers, students, and others who are al- lowed to reside in the United States for longer than a year on nonimmigrant visas; they make up a very small share of the migrant flow from Mexico.21 We used a CHIS method to esti- mate the size of California’s undocumented population; our find- ing was very close to independent estimates based on national data.22 In addition, any bias that these legally authorized indi- viduals introduce to the undocumented category is assumed to be positive (ie, more use of and access to health care ser- vices), resulting in more conservative comparisons. We treat this entire group as undocumented, because the characteris- tics of the undocumented residents dominate the group. Herein we use the term undocumented, with the caveat that a relatively small proportion may have been misclassified.

Other Measures

In addition to race and ethnicity, our multivariate models con- trol for sociodemographic, economic, and health-related factors that commonly affect access to, use of, and experiences with health care resources.23 Sociodemographic factors include sex, marital status (married and other), age (18-34, 35-49, 50-64, 65-74, or �75 years), educational achievement (less than high school gradu- ate, high school graduate, or more than high school), and loca- tion of residence (urban, suburban, or rural). Economic vari- ables include employment (employed, unemployed, or not in labor force), federal poverty level (0%-99%, 100%-199%, or �200%), and whether the subject had any health insurance (insured or un- insured). We also controlled for self-reported health status (poor, fair, good, very good, or excellent).

STATISTICAL ANALYSIS

We used commercially available software (SAS, version 9.1; SAS Institute, Cary, North Carolina) for all statistical analyses.24 First, we used �2 tests to describe the sample population by demo- graphics, health insurance, and self-reported health status in terms of race/ethnicity and citizen/documentation status. Sec- ond, we used �2 tests and analysis of variance to compare health care access (usual source of care and problems in getting nec- essary health care in the past 12 months) and use of health care services (number of physician visits in the past 12 months, hav- ing had at least 1 physician visit in the past 12 months, and having used the ED in the past year) for each of the racial/ ethnic and citizen/documentation categories. We also com-

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pared the experiences in care measures (difficulty understand- ing the physician during the last health care visit, thinking that one might get better care if he or she were of a different race or ethnicity, and rating of all health care received in the past 12 months) for each of the racial/ethnic and citizen/documen- tation categories. Third, we conducted multivariate analyses using logistic regression for binary measures and ordinary least squares regression for continuous measures for the samples of Mexican and US-born white respondents; US-born Mexicans constituted the reference category. Fourth, we conducted the same multivariate analyses for the sample of other Latino and US-born white respondents; other US-born Latinos consti- tuted the reference category. The multivariate models were each adjusted for sex, marital status, health insurance, age, educa- tion, employment status, federal poverty level, location of resi- dence, and self-reported health status. We report odds ratios for logistic regressions and estimation coefficients for ordi- nary least squares regressions.

RESULTS

Regarding their descriptive characteristics within the Mexican and other Latino samples, the undocumented immigrants constitute the lowest proportions with health insurance and are the youngest (Table 1). Most Lati- nos, in general, are employed, including undocu-

mented individuals. Patterns of poverty follow immigra- tion status for Mexicans and other Latinos, with the highest percentage of adults below the federal poverty level among undocumented individuals, followed by green card holders, naturalized citizens, and US-born Mexi- cans. Compared with almost half of undocumented Lati- nos, approximately 5% of US-born white subjects live at less than 100% of the federal poverty level.

The undocumented immigrants are the least likely to report their health status as poor among Mexicans and other Latinos. In both groups, most reported their health as fair or good, whereas a much smaller proportion reported their health to be very good or excellent. In contrast, higher pro- portions of US-born Latinos reported their health as good to excellent. The US-born white respondents were more likely than any Latinos to have insurance and to report their health status as very good or excellent.

Among Mexicans, the undocumented immigrants re- ported the lowest proportion of having a usual source of care, followed by green card holders, naturalized citi- zens, and US-born citizens (Table 2). Among other Lati- nos, the undocumented immigrants also had the lowest proportion with a usual source of care, followed by green card holders, US-born citizens, and then naturalized citi-

Table 1. Descriptive Statistics by Race, Ethnicity, and Citizen/Documentation Status: CHIS 2003 a

Variable

Mexican Other Latino

US-Born White

US Born Naturalized

Green Card Undocumented

P Value b

US Born Naturalized

Green Card Undocumented

P Value c

No. of respondents 2851 1218 1352 1317 852 546 327 271 23 178 Female 59.7 55.8 54.8 54.8 �.01 56.1 61.4 54.4 56.5 .13 58.8 Married 44.9 66.1 64.4 49.0 �.01 39.0 56.8 48.9 37.3 �.01 51.4 Health insurance 85.2 79.5 67.5 47.2 �.01 84.4 84.4 69.1 43.2 �.01 92.8 Age, y

18-34 43.4 20.4 36.2 66.1

�.01

33.1 18.7 29.7 52.0

�.01

16.1 35-49 29.2 42.6 45.9 29.3 33.2 37.2 46.2 40.6 28.6 50-64 17.2 24.4 13.0 4.0 20.3 26.7 15.9 5.9 29.4 65-74 6.1 8.7 3.9 0.5 7.8 10.8 5.8 1.1 13.2 �75 4.1 3.9 1.0 0.2 5.6 6.6 2.4 0.4 12.7

Educational achievement �High school 15.2 46.2 63.8 69.6

�.01 12.5 21.6 37.6 54.2

�.01 4.7

High school graduate 37.0 24.6 20.0 20.4 28.2 21.6 22.0 19.6 23.6 �High school 47.8 29.2 16.2 10.0 59.3 56.8 40.4 26.2 71.7

Employment Not in labor force 27.1 34.0 30.2 30.1

�.01 29.4 28.4 26.6 23.2

.01 37.9

Unemployed 7.2 4.3 9.5 8.9 7.6 5.1 9.8 12.2 3.0 Employed 65.7 61.7 60.4 61.0 63.0 66.5 63.6 64.6 59.1

Federal poverty level, % 0-99 14.0 21.0 35.9 55.1

�.01 11.3 15.9 31.2 46.9

�.01 5.3

100-199 23.6 34.2 41.2 34.4 17.5 24.4 31.8 36.9 12.4 �200 62.4 44.8 22.9 10.5 71.2 59.7 37.0 16.2 82.3

Location of residence Urban 74.6 78.7 73.1 81.6

�.01 72.7 82.4 86.9 92.6

�.01 59.4

Suburban 13.5 9.0 8.0 6.9 15.5 12.1 10.4 5.2 18.5 Rural 11.9 12.3 18.9 11.5 11.8 5.5 2.7 2.2 22.1

Health status Poor 5.0 8.0 6.7 3.0

�.01

5.5 5.9 5.5 3.3

�.01

4.5 Fair 14.1 27.3 31.0 36.9 14.6 20.0 28.8 32.5 10.4 Good 29.2 32.5 37.2 42.1 26.6 29.3 31.2 36.5 25.0 Very good 31.9 17.1 13.3 9.1 31.1 26.7 18.4 14.4 35.4 Excellent 19.8 15.1 11.8 8.9 22.2 18.1 16.2 13.3 24.7

Abbreviation: CHIS, California Health Interview Survey. a Unless otherwise indicated, data are expressed as percentage of respondents. b Calculated by means of �2 tests within Mexican and US-born white samples. c Calculated by means of �2 tests within other Latino and US-born white samples.

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zens. Among Mexicans, naturalized citizens and undocu- mented immigrants reported the highest proportion of problems in obtaining necessary health care in the past 12 months. The findings are different for other Latinos, among whom the US-born citizens are more likely to re- port having problems.

In the Mexican and other Latino groups, the undocu- mented immigrants and green card holders had the low- est mean number of physician visits in the last year and constituted the lowest proportions of those with at least 1 physician visit in the past year. In both groups, un- documented individuals and green card holders had the smallest proportions of those with at least 1 visit to an ED in the past year, whereas the US-born and natural- ized citizens had the highest proportions of those with at least 1 visit to an ED.

The undocumented immigrants in both groups consti- tuted the highest proportions of those having difficulty un- derstanding their physicians during their last visit and think- ing that they would get better care if they were of a different race or ethnicity. For both of those measures, undocu- mented immigrants are followed sequentially by green card holders, naturalized citizens, and then US-born citizens. Mean differences are found for the ratings of all health care received in the past 12 months, but the differences are mar- ginal, with US-born Mexicans having the lowest mean rat- ings and naturalized citizens having the highest. For other Latinos, the differences are also small, with undocu- mented immigrants having the lowest mean ratings and naturalized citizens having the highest.

In multivariate analyses (Table 3) comparing US- born Mexicans, undocumented Mexicans, and Mexican

green card holders, the Mexico-born groups are less likely to have a usual source of care, are less likely to report having had a problem in getting necessary health care in the past 12 months, have a lower mean number of phy- sician visits in the past year, are less likely to have had at least 1 physician visit in the past year, are less likely to have used an ED in the past year, have higher odds of reporting difficulty understanding their physicians dur- ing the last visit, are more likely to report that they would receive better care if they were of a different race or eth- nicity, and have a higher mean rating of all health care received in the past 12 months.

Within the other Latino sample, compared with the US-born citizens, undocumented immigrants and green card holders have lower odds of reporting difficulty ob- taining necessary health care in the past year, have a lower mean number of physician visits in the past year, are less likely to have been to an ED in the past year, have higher odds of reporting a hard time understanding their phy- sicians during the last visit, and have higher mean rat- ings of all their health care in the past year (Table 4). The undocumented immigrants are less likely to have a physician visit during the previous year, and green card holders have a higher likelihood of reporting that they would receive better care if they were of a different race or ethnicity compared with other US-born Latinos.

COMMENT

Trends in access to and use of health care services across the Latino groups by documentation and citizenship status

Table 2. Health Care Access, Use of Services, and Experience by Race/Ethnicity and Citizen/Documentation Status a

Variable

Mexican Other Latino US- Born

White US

Born Naturalized Green Card Undocumented

P Value b

US Born Naturalized

Green Card Undocumented

P Value c

Health care access Usual source of health care 88.3 87.4 79.4 65.7 �.01 86.9 90.5 84.1 62.0 �.01 92.5 Problem getting necessary health

care in past year 16.3 17.5 14.0 17.8 .03 21.1 19.7 17.4 17.2 �.01 15.4

Use of health care services No. of physician visits in past year

Mean d 4.08 4.13 3.42 2.36 �.01

4.71 4.03 3.46 2.27 �.01

4.75 Median 2.00 2.00 2.00 1.00 2.00 2.00 2.00 1.00 3.00 IQR 1-5 1-5 0-4 0-1 1-5 1-4 1-4 0-3 1-6

�1 Physician visit in past year 82.9 84.7 73.6 64.5 �.01 86.0 89.0 81.0 66.8 �.01 87.3 �1 ED visit in past year e 20.7 16.0 13.7 13.8 �.01 21.7 20.3 17.0 16.0 .02 18.8

Health care experience Hard time understanding physician

during last visit 3.8 7.1 9.0 12.3 �.01 2.7 6.5 9.5 10.3 �.01 2.6

Would get better care if different race/ethnicity

6.4 12.0 15.3 20.3 �.01 8.4 9.9 18.0 18.5 �.01 2.5

Rating of all health care in past year f

Mean d 8.11 8.41 8.38 8.24 �.01

7.83 8.07 7.84 7.60 �.01

8.17 Median 8.00 9.00 9.00 9.00 8.00 8.00 8.00 8.00 8.00 IQR 7-10 8-10 8-10 8-10 7-10 7-10 7-10 7-10 7-10

Abbreviations: ED, emergency department; IQR, interquartile range. a Unless otherwise indicated, data are expressed as percentage of respondents. b Calculated by means of �2 tests within Mexican and US-born white samples. c Calculated by means of �2 tests within other Latino and US-born white samples. d Calculated by means of analysis of variance for continuous variables. e From the 2001 California Health Interview Survey. f Zero indicates the lowest and 10 the highest score.

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suggest that considering Latinos as a monolithic group masks important differences. Our results demonstrate that use of health care services by Latino immigrants is lower than that of US-born Latinos and white subjects. For most measures, patterns of increasing use of services follow the continuum of immigration status from lack of docu- mentation to naturalization.

The differences in access to, use of, and experiences with health care among Latino immigrant and citizen groups have implications for efforts to eliminate health care disparities. For example, worse health care experi- ences for undocumented Mexicans imply that efforts to improve processes of care need to address this specific vulnerable group. Strategies to improve the delivery of health care services to legally authorized immigrants and US citizens, to the exclusion of undocumented individu-

als, will likely miss an opportunity to influence health care for the individuals most affected by inequities in health care access.

Undocumented Mexican immigrants in California are less likely to have a usual source of care compared with US-born Mexicans, even after controlling for sociode- mographics, insurance, and need. A similar pattern is ob- served for undocumented Latino immigrants from coun- tries other than Mexico, although the findings are not statistically significant. An interesting finding is that al- though studies show that having a usual source of care reduces racial and ethnic differences in receipt of pri- mary and preventive services25,26 and reduces nonur- gent visits to the ED within a general population,27,28 un- documented Latino immigrants in this study do not have higher ED use than their US-born counterparts, despite

Table 3. Multivariate Analysis for Mexican and US-Born White Samples

Variable Model a

Mexican US-Born WhiteUS Born Naturalized Green Card Undocumented

Health care access Usual source of health care Logistic (OR) Reference 0.82 0.75 b 0.70 b 0.83 b

Problem getting necessary health care in past year Logistic (OR) Reference 0.99 0.61 b 0.68 b 1.22 b

Use of health care services No. of physician visits in past year OLS (coefficient) Reference −0.36 −0.81 b −1.55 b 0.66 b

� 1 Physician visit in past year Logistic (OR) Reference 1.28 c 0.83 c 0.73 b 1.06 � 1 ED visit in past year d Logistic (OR) Reference 0.70 b 0.52 b 0.50 b 1.00

Health care experience Hard time understanding physician during last visit Logistic (OR) Reference 1.45 c 1.43 c 1.72 b 0.98 Would get better care if different race/ethnicity Logistic (OR) Reference 1.68 b 1.67 b 1.93 b 0.55 b

Rating of all health care in past year e OLS (coefficient) Reference 0.32 b 0.55 b 0.74 b −0.28 b

Abbreviations: ED, emergency department; OLS, ordinary least squares; OR, odds ratio. a Adjusted for sex, marital status, health insurance, age, education, employment, federal poverty level, location of residence, and self-reported health status. b Significant at the 1% level. c Significant at the 5% level. d Emergency department visit information is from the 2001 California Health Interview Survey. e Zero indicates the lowest and 10 the highest score.

Table 4. Multivariate Analysis for Other Latino (Not Mexican) and US-Born White Samples

Variable Model a

Other Latino US-Born WhiteUS Born Naturalized Green Card Undocumented

Health care access Usual source of health care Logistic (OR) Reference 1.07 1.23 0.72 0.97 Problem getting necessary health care in past year Logistic (OR) Reference 0.88 0.54 b 0.40 b 0.89

Use of health care services No. of physician visits in past year OLS (coefficient) Reference −0.97 b −1.38 b −2.06 b 0.04 � 1 Physician visit in past year Logistic (OR) Reference 1.16 0.91 0.64 c 0.81 c

� 1 ED visit in past year d Logistic (OR) Reference 0.93 0.68 b 0.56 b 0.95 Health care experience

Hard time understanding physician during last visit Logistic (OR) Reference 2.35 b 2.55 b 2.25 b 1.28 Would get better care if different race/ethnicity Logistic (OR) Reference 1.13 1.52 c 1.08 0.38 b

Rating of all health care in past year e OLS (coefficient) Reference 0.18 0.32 b 0.51 b 0.01

Abbreviations: ED, emergency department; OLS, ordinary least squares; OR, odds ratio. a Adjusted for sex, marital status, health insurance, age, education, employment, federal poverty level, locality of residence, and self-reported health status. b Significant at the 1% level. c Significant at the 5% level. d Emergency department visit information is from the 2001 California Health Interview Survey. e Zero indicates the lowest and 10 the highest score.

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their lower rates of having a usual source of care and in- surance coverage. Undocumented Latino immigrants also have fewer routine physician visits than US-born Mexi- can and white subjects. Although we cannot attribute the effects of differences in health care access, there is a ten- dency for the undocumented immigrants to report only fair or good health status compared with their US-born counterparts, who were more likely to report their health as good, very good, or excellent.

A seemingly counterintuitive finding is that despite lower rates of use of health care services, foreign-born Latinos report fewer problems accessing needed care and higher ratings of their health care compared with US- born Latinos. A likely explanation is that foreign-born Latinos experience fewer problems obtaining health care because of fewer attempts to access care. It could also be that they are comparing their experiences in the US health care system with those in the systems in their countries of origin, and that they are more satisfied with the health care of the United States. Our findings regarding lower use of health care services among undocumented Lati- nos are consistent with other studies of immigrants.12,13

The overall lower rate of use of health care services and poorer self-rated health status among undocumented im- migrants suggest a need to better understand the impact of low rates of use of health care services for Latino im- migrants in general and undocumented Latino immi- grants in particular. Poor use of health care resources could have important implications with regard to the health of a growing segment of the population.

All foreign-born Latino immigrants are more likely than US-born Latinos to perceive that they would have re- ceived better care if they were of a different race or eth- nicity, and US-born Latinos are more likely to believe this than US-born white subjects. A previous CHIS study found that foreign-born individuals were more likely to report discrimination in health care than US-born individu- als.5 A separate study observed that Latinos consider dif- ferential treatment by health care …