As of 2021, nearly 45.3 million immigrants resided in the United States. Among immigrants, roughly 23% live without legal documented status. Recent implementation of anti-immigrant policies (e.g., public charge rule, family separation, increased ID restrictions, etc.), escalation of racialized hate and discrimination, and the continued bipartisan push to overhaul the U.S. immigration system have all elevated the pertinence of immigrant documentation status as a potential determinant of health. The different types of immigrant documentation status include: legal permanent residents (i.e., green card holders), non-immigrant visa holders and dependent work authorization holders (e.g., students, tourists, and temporary workers), asylees, refugees, and undocumented immigrants (i.e., foreign-born individuals who reside in the U.S. without lawful immigration status, including those with quasi-legal statuses such as Temporary Protected Status or Deferred Action for Childhood Arrivals, DACA, recipients). Immigration status is now understood as a key social determinant of health (SDOH) and a critical contributor to racial health inequities, yet major gaps in evidence remain.
Immigrant documentation status may be incorporated within an SDOH framework through dimensions such as impacts on economic, educational, and occupational opportunities and disruption of social and family networks. The health effects of immigration are shaped by individual ethnicity, gender, and other social identities. Connections between immigrant documentation status and health inequities have been recognized to operate through several mechanisms, including access to and use of healthcare services through insurance coverage, access to health protective resources (e.g., Supplemental Nutrition Assistance Program, Temporary Assistance for Needy Families, and Women, Infants, and Children Nutrition Program), and immigration enforcement laws such as detention, deportation, and family separation. At Evidence for Action, we emphasize the value of structural frameworks to intervene and to advance racial and health equity. Here, we draw on this framework to discuss current methodologic challenges in studying immigrant documentation status.
Example Research Questions
Immigration law and policy context is not static and pathways to legal status in the U.S. may differ by timing of application and entrance into the U.S. For instance, federal court rulings over the past few years declaring DACA as illegal will have detrimental consequences to immigrant children if protections against deportation are removed. In addition, with the program stuck in litigation, the program has been frozen in place with the number of individuals with DACA seeing an overall downward trend since 2018. Capturing the details of an immigrant's documentation status over the next few years will allow us to understand and disrupt the direct and indirect health equity impacts of court rulings on DACA and other changing immigration policy contexts.
Anti-immigrant policies create structural barriers that impact immigrants differently by documentation status and by race and ethnic groups. Without legal authorization, immigrants may be denied access to social programs and public benefits. Ignoring immigrant documentation status in racial and health equity research is a missed opportunity to understand critical systemic barriers to achieving health. In 2019, the Public Charge Rule was implemented and made it harder to obtain green cards or visas for immigrants who receive public cash assistance. However, misinformation and fear of becoming a public charge may lead immigrants to not take up other non-cash public benefits like nutrition programs (e.g., Supplemental Nutrition Assistance Program, Special Supplemental Nutrition Program for Women, Infants, and Children) and health programs (e.g., Children’s Health Insurance Program, Medicaid). Such policies not only impact the eligibility to obtain legal status in the U.S. but also indirectly impact food security and their health when systems force individuals to prioritize legal status over their health and well-being.
Possible Approaches Around Existing Challenges
One of the methodologic challenges in research examining immigrant documentation status arises due to the limited number of public datasets with comprehensive information in this domain. Collecting and reporting information on documentation status can place research study participants at risk of punitive repercussions, such as deportation, if a breach of privacy or confidentiality occurs. Many researchers avoid asking about documentation status because of this risk and, even if asked, research participants may hesitate to respond. Yet, information on immigrant documentation status can provide an opportunity to deconstruct systemic racism by improving health research in connection to immigrant documentation status, policies, and interventions.
Immigrant documentation status is typically assessed through either self-report or a derived proxy measure. Common proxy measurements rely on lacking or having other documentation, such as a valid Social Security Number (SSN), a driver’s license, or certain types of public health insurance. The legal exclusions experienced by immigrants with undocumented status are noted to differ from the social constructs measured by proxies. One solution may be to frame the variable as what it measures. Namely, having a valid SSN can be conceptualized as having access to legal resources to naturalize, if foreign-born, and consequently, the access to governmental protections in the U.S. The distinct conceptualizations of documentation status must be addressed, particularly when using proxy measurements to deduce the legal element of documentation status.
Thus far, there is limited work on the validity and reliability of measures of immigrant documentation status and in relation to health. To compare findings across studies, we need to assess the validity and reliability of the measures used, response rates, patterns of missingness, and accurately report how we handle the missingness of documentation status (e.g., imputation). Validation of common methods to estimate immigrant documentation status is scarce and limited to testing within data sources in the 2000’s. Prior research suggests that a probabilistic approach is the least biased. This method uses prediction models where the probability of being undocumented is estimated as a function of relevant demographic and health variables (e.g., gender, age, poverty, year of immigration, self-rated health) and interactions between them and insurance coverage. It is important to note that adding commonly used variables (e.g., federal assistance receipt) may reduce the prediction model’s performance. Bias analyses of these self-report and proxy methods and estimation of prediction models in alignment with recent immigration patterns and data sources are needed.
Several potential research programs could help fill critical gaps. First, validation of current methods to understand documentation status is critically needed. Second, methods to crosswalk studies with alternative approaches to measuring documentation status need to be developed to overcome data scarcity, improve meta-analyses, and promote evidence triangulation. Third, ongoing studies should critically consider the ethical and scientific benefits and potential risks of obtaining identifiable participant information to capture documentation status among foreign-born populations. Finally, a major assumption and limitation in current research is the researcher bias to implicitly assume that immigrant participants do not want to directly disclose legal status. Greater qualitative research is needed to understand the immigrant population’s perceptions, experiences, and potential health equity impact of documentation status.
Putting Evidence Into Practice
Research to highlight health mechanisms, experiences of discrimination, and experiences of obtaining legal status while navigating changing policy contexts, legal and financial resources, housing, food security, and health services may be few ways to shed light into our current understanding of the health impacts of documentation status.
There are continued and growing efforts in building the scientific evidence to understand immigration and documentation status as a SDOH in racial and health equity research. Capturing immigrant documentation status precisely and thoughtfully will provide an opportunity to expand our current knowledge of immigrant racial and health inequities to inform policies and interventions.