In the Shadows

Introduction: Black undocumented immigrants face dual barriers to care access based on their legal status and due to structural racism in US society. Prior work has shown that Black immigrants (and particularly undocumented immigrants) are less likely to be insured than the general population. However, less is known about other dimensions of health care access for Black undocumented immigrants. Methods: This study analyzes nationally representative data from the National Health Interview Survey (NHIS) from 1999 to 2018 to examine health care access and outcomes along the axes of legal status (undocumented, documented, naturalized citizen, and US-born citizen) among Black individuals aged 40 and above. We analyzed clinician visits over the past 2 years and overnight hospitalizations over the past year (the latter for individuals aged 40 y and older). Non-Hispanic White US-born citizens (NHWC) were used as the reference category. Results: Among Black individuals across legal strata, Black undocumented immigrants had higher odds of uninsurance (OR: 4.7 95% CI: 3.6, 6.0), having no recent physician encounters in the previous 2 years (OR: 1.7; 95% CI: 1.2, 2.3), including lower odds of emergency room visits (OR: 0.7, 95% CI: 0.5, 0.9) and overnight hospital visits (OR: 0.5; 95% CI: 0.4, 0.7) in the past year. They also had lower odds of any blood pressure measurements (OR: 0.5; 95% CI: 0.38, 0.77) in the past year, and women aged 40 had lower odds of ever having received cervical cancer screening (OR: 0.1; 95% CI: 0.1, 0.2). Across all categories, utilization decreased with less secure legal status. Causal mediation analysis showed that insurance status played an important role in the relationship between undocumented status and having had a recent physician visit, mediating 2.7 (95% CI: 1.2%, 4.0%) of the 5.1-point gap (95% CI: 1.7%, 8.7%) between Black undocumented adults and NHWC. Conclusions: The relationship between race and legal status is complex. Legal status is significantly associated with access to insurance and outpatient care among Black immigrants.