In both countries, immigrants had worse access to care than nonimmigrants for some indicators but not others, providing some evidence in favor of the hypothesis that foreign birth is a risk factor for poor access to primary and preventive care. However, few differences in access to care were found when direct cross-country comparisons were made between immigrants in Canada versus the United States, after accounting for sociodemographic differences.
It was hypothesized that immigrants' access to care would be better if they lived in Canada, where universal health coverage is provided, versus the United States, where insurance coverage is fragmented and often excludes foreign-born populations. Indeed, in unadjusted analyses, immigrants living in Canada had better access to care compared with immigrants living in the United States. On the other hand, immigrants who realized access to care in both countries reported similar rates of satisfaction with care and perceived quality of care. These findings suggest that although there are disparities in access to care across countries, once immigrants in each country achieve access they are equally content with their overall health care experiences. One explanation for this is that immigrants who have access to care may be endowed with more enabling resources than those without access, and those same resources may also help them obtain higher quality care.
Most of the differences in access were explained by differences across the two countries in socioeconomic status (i.e., education, income quintile, racial origin) and insurance coverage among immigrants. Adjusting for demographic and socioeconomic covariates effectively served to eliminate the effect of country of residence on access to care for all measures except Pap tests, and partly explained immigrants' barriers to primary and preventive care. Additionally adjusting for insurance status differences within the United States further attenuated the disparities across countries for having a regular medical doctor, having a health professional consultation, mammograms, and having any unmet health care needs.
A counterintuitive finding, however, was that immigrants in Canada were less likely to have a timely Pap test than immigrants in the United States, indicating that barriers to care remain for Canadian immigrants despite the country's universal health coverage. One potential explanation for this result may be that the United States has targeted efforts at increasing cancer screening among minority and low-income populations, and thus has successfully reached immigrants who tend to fit these sociodemographic profiles (Smedley, Stith, and Nelson 2003
; National Center for Chronic Disease Prevention and Health Promotion 2009a
). Cervical cancer screening in Canada, on the other hand, has largely been “ad hoc” or opportunistic rather than through an organized screening program, and although certain provinces have implemented their own population-based screening programs these do not seem to specifically target underserved populations (Public Health Agency of Canada, Health Canada 2002
). In addition, the U.S. Department of Health and Human Services introduced the National Standards on Culturally and Linguistically Appropriate Services in 2001, representing one federal attempt at promoting access to health care among diverse populations (Office of Minority Health 2007
). In Canada, however, language barriers in access to care have been recognized, and regional or provincial service provision models have been developed, but no national standards of practice have been established to date (Bowen 2001
; Pottie 2007
; Goggins 2008
Alternatively, it may be that the composition of immigrant populations are different in each country, and that there are unique cultural or behavioral barriers to Pap tests among immigrants to Canada, which have not been sufficiently addressed through the provision of universal health care. Although data limitations in the JCUSH prevented us from comparing immigrant composition across countries, Census data show that the United States receives more Hispanic immigrants than Canada, which receives a greater proportion of Asian immigrants (Passel and Suro 2005
; Citizenship and Immigration Canada 2007
; Terrazas et al. 2007
;). Previous research has found that among immigrants to the United States, Latinas have a greater likelihood of receiving cervical cancer screenings than whites or Asians (De Alba et al. 2005
); Pap test rates may be higher in the United States because of higher fertility rates among Latina immigrants, which brings them into contact with the health care system (Gonzales 2008
). In Canada, Asian immigrants have significantly lower rates than Canadian-born women and other immigrant groups, even after many years of residence (McDonald and Kennedy 2007
). These demographic differences may be associated with more barriers among Asian immigrants to Canada due to lack of knowledge of health-related issues and the health care system, cultural attitudes and beliefs, gender roles, or lack of culturally appropriate services (Lai and Chau 2007
; Maticka-Tyndale, Shirpak, and Chinichian 2007
; Wang 2007
; Brotto et al. 2008
; Roth and Kobayashi 2008
; Wang, Rosenberg, and Lo 2008
;). Given that the survey was not conducted in Asian languages, immigrants from Asian countries (especially newer immigrants with limited English proficiency) may have been underrepresented in the JCUSH data; thus, the low Pap test rates in Canada may in fact overestimate the true rates, which may be even lower.
There were several limitations with this study. First, due to the lack of availability in the JCUSH dataset, some important determinants were not included in the analyses, including citizenship, length of stay, language proficiency, country/region of origin, and health beliefs. We expect that their inclusion would have highlighted barriers to care among noncitizen immigrants in the United States; differences in access to care between immigrants in Canada and the United States would have been accentuated because health insurance coverage in the former country is universal and not dependent on citizenship status. Length of stay would also likely be identified as a barrier to care in both countries, with more recent immigrants having worse access than more established immigrants. Information on language proficiency would probably have revealed worse access to care among Spanish-speaking immigrants in the United States, and even worse access among immigrants who spoke another language besides English or Spanish. Although Canada is officially a bilingual country committed to the provision of services in English and French, immigrants who are not fluent in either of these languages would also be expected to have worse access to care. Finally, there are differences between immigrants to Canada and those to the United States, besides the obvious difference in insurance coverage, which heighten the disparities in access across countries. Specifically, Canadian immigrants typically have higher education levels and higher incomes compared with U.S. immigrants. We controlled for these differences in the multiple regression analyses, which accounted for many of the disparities, but such socioeconomic factors may be associated with other resources that enable access to care, including health beliefs, knowledge about the health care system, English proficiency, and so on. Inclusion of these types of variables might also help explain some of the disparities.
As well, the random digit dialing procedure excluded households without landline telephones, leading to potential biases. The percentage of households with no telephone is quite small, 1.8 percent in Canada and 4.4 percent in the United States (Sanmartin et al. 2004
). In addition, poststratification techniques allowed for inferences to be made for the entire population, whether or not the households have telephone service. However, it is possible that immigrants were underrepresented in the sample. If this is the case, the disparities in access to care between the foreign-born and the native-born documented in this study were likely underestimated.
Similarly, surveys were only conducted in English and French (in Canada) and English and Spanish (in the United States), excluding households who only spoke other languages. Consequently, linguistically isolated households, especially newer immigrants, were more likely to be underrepresented in the survey. According to census data, about 10 percent of immigrants in both countries live in such households (Statistics Canada 2001a
; Shin and Bruno 2003
; Larsen 2004
;), and they are more likely to experience barriers to care than native-born individuals. Therefore, due to the language requirements for participation in the survey, the barriers in access to care for immigrants were likely conservatively estimated.
Another limitation is that JCUSH survey response rates were relatively low compared with other national health surveys. The rates were 65.5 percent in Canada and 50.2 percent in the United States, compared with 80.7 percent in the Canadian Community Health Survey and 74.2 percent in the U.S. National Health Interview Survey from the same year (National Center for Health Statistics 2004
; Statistics Canada 2005
). However, these latter surveys included in-person interviews, which tend to have higher response rates than telephone surveys. In addition, telephone survey response rates generally have been declining over the past few decades so this issue is not limited to the JCUSH. Furthermore, recent research has demonstrated that nonresponse often produces no or minimal bias, and that biases may be addressed through adjustments in survey weights, as was done in the JCUSH (Singer 2006
; Kempf and Remington 2007
Despite these limitations, this study contributes to the existing literature by examining the relationship between immigrant status and primary and preventive care, using a broad spectrum of indicators measuring access, utilization, and patient perceptions, in two primary migrant destinations. It uses the JCUSH dataset, which is the first multicountry survey using a single questionnaire and a standardized methodology, thus allowing for nationally representative, direct comparisons between Canada and the United States. Many previous studies have considered access to care in either Canada or the United States, but few have simultaneously compared results from the two countries. This study builds on previous analyses by including a wide array of outcome measures, and providing a comprehensive report of immigrants' health care experiences in North America.
Comparisons within and across countries indicate that health insurance coverage plays an important role in ensuring immigrants' access to care. To the extent that the health of these nations is increasingly being reflected by the health of a growing population of immigrants, policy makers interested in promoting their country's health and productivity, and reducing health care disparities, may want to consider expanding insurance coverage options for the foreign born. This is especially true in the United States, where undocumented immigrants receive no benefits or protection, and even documented immigrants are explicitly excluded from eligibility for federally funded health insurance for the first 5 years after arrival (Derose, Escarce, and Lurie 2007
). The majority of the U.S. population receives insurance coverage through employers, but many immigrants work in low-paying jobs that do not offer affordable employer-sponsored insurance and thus they remain uninsured (Capps et al. 2002
; Derose et al. 2007
;). While much of the policy debate surrounding health care coverage for immigrants in the United States has focused on unauthorized immigrants, 70 percent of the foreign-born population (28.0 million) in fact resides in the country legally (Passel and Cohn 2009
). Two-thirds of immigrants are working, and while the foreign born make up 12 percent of the total population, they make up over 16 percent of the labor force (Larsen 2004
; Passel and Cohn 2009
). Thus, a large proportion of the foreign-born population merits consideration in policy efforts to improve access to care.
At the same time, health insurance should not be viewed as a panacea for assuring access to care for immigrants and other vulnerable populations. Indeed, disparities in access based on immigrant status persist in Canada, indicating that other barriers to care exist and have not yet been adequately addressed. In addition, stark socioeconomic differences exist across foreign-born populations in each country, with a greater proportion of immigrants in the United States being racial/ethnic minorities and having lower education and income levels, compared with immigrants in Canada. Accounting for these differences reduces or eliminates access disparities across countries, suggesting that immigrants' access to care in the United States may also be improved by broader policy interventions aimed at improving access more generally among racial/ethnic minorities and populations with lower socioeconomic status.