Disparities in Access to Health Care Among US-Born and Foreign-Born US Adults by Mental Health Status, 2013–2016

Abstract

Objectives. To compare access to care between US-born and foreign-born US adults by mental health status.

Methods. We analyzed data on nonelderly adults (n = 100 428) from the 2013–2016 National Health Interview Survey. We used prevalence estimates and multivariable logistic regression models to compare issues of affordability and accessibility between US-born and foreign-born individuals.

Results. Approximately 22.2% of US-born adults and 18.1% of foreign-born adults had symptoms of moderate to severe psychological distress. Compared with US-born adults with no psychological distress, and after adjustment for sociodemographic characteristics, US-born and foreign-born adults with psychological distress were much more likely to report multiple emergency room visits and unmet medical care, mental health care, and prescription medications because of cost.

Conclusions. Our study found that adults with moderate to severe psychological distress, regardless of their immigration status, were at greater risk for reporting issues of affordability when accessing health care compared with US-born adults with no psychological distress.

Public Health Implications. Health care and mental health reforms should focus on reducing health care costs and establishing innovative efforts to broaden access to care to diverse populations.

Health care access is an important factor associated with mental illness prevention, early-stage diagnosis and treatment, and overall prognosis of psychiatric disorders.¹ However, disparities in health care access and health services utilization between immigrants and native-born populations in the United States have been well documented for a number of reasons, including stigmatization, fear of deportation, challenges navigating a complex health insurance system, and the absence of culturally sensitive care and health information.^2,3 Studies show that, on average, immigrants report better self-rated health and less health services utilization compared with native-born populations. However, considerable debate remains over whether lower utilization rates reflect a lesser need or an issue of accessibility.^4–7 This problem can be unremitting and even aggravated in the treatment of mental health disorders, which are among the most expensive medical conditions in the United States in recent years.⁸

There are a variety of factors that influence the mental health of immigrants in particular. First, it is essential to recognize that immigrants enter the United States through a variety of means, including elective immigration (e.g., family-based and employment-based immigration) and forced migration (e.g., refugees or asylees who are fleeing persecution or are unable to return to their homeland because of life-threatening and oftentimes extraordinary conditions). Depending on the reason for relocation, immigrants may experience resettlement stress during the acclimation and adjustment period caused by changes in socioeconomic status. Isolation and absence of social support may also serve as catalysts for undue stress to develop into persistent psychiatric pathology and reduced quality of life.^9,10 Furthermore, traumatic and adverse life experiences, particularly in the refugee and asylee population, serve as forerunners for acute stress disorder and posttraumatic stress disorder in these groups.^9,10 Because immigrants and children of immigrants constitute 24% of the US population,¹¹ their mental health concerns—and acculturative stress in particular—have ramifications for the overall health of the nation.

Although immigrants may have greater mental health care needs, barriers to medical and mental health care may prevent some immigrants from accessing needed treatment. For instance, immigrants are at higher risk for encountering hostile attitudes in the health care delivery system,¹² which impedes access to routine medical care for this vulnerable population. Evidence suggests that heightened vigilance related to perceived prejudice also has pathogenic effects on the mental health of immigrant populations.¹² A recent study of Hispanics in 38 states found higher rates of mental illness in states with more exclusionary policies and attitudes toward immigrants.¹³ Other research suggests that some immigrant groups may experience barriers to medical care,¹¹ but very little research has directly examined access to care for immigrants living with psychological distress in the United States.

This study compared access to care and health services utilization between US-born and foreign-born US adults by mental health status. We hypothesized that foreign-born individuals with moderate or severe psychological distress may be more likely to face barriers to care compared with US-born individuals with no psychological distress. Knowing the patterns in health care access between these groups across a spectrum of mental health statuses is important for informing ongoing efforts to narrow health disparities between immigrant and native-born populations in the United States.

METHODS

This study used data from the 2013–2016 National Health Interview Survey (NHIS), a nationally representative health survey of the civilian, noninstitutionalized population. Conducted annually by the National Center for Health Statistics at the Centers for Disease Control and Prevention, the NHIS provides comprehensive data used to monitor the nation’s health.¹⁴ The questionnaire records basic demographic, health, and disability information for each household member. A single random adult in each household is selected for a detailed interview on more specific health information, including health insurance coverage, access to health care, and health services utilization. We drew our study sample from the sample adult component of the 2013–2016 NHIS, which we accessed through the University of Minnesota’s Integrated Public Use Microdata Series, a systematized and publicly available version of the NHIS.¹⁵

We used demographic data from sampled adults to identify nonelderly US-born and foreign-born adults in the NHIS. Consistent with previous research using the NHIS, US-born adults included all adults born in 1 of the 50 states, the District of Columbia, or any US territory.^16,17 The NHIS considered adults born outside the United States and its territories to be foreign-born; they might include naturalized citizens, legal permanent residents, refugees, undocumented immigrants, and adults on long-term temporary visas (e.g., students and guest workers). We restricted the analysis to nonelderly adults aged 18 to 64 years (n = 104 196) to examine health care needs in the working-age population. Our final sample included 85 217 US-born adults and 18 979 foreign-born adults.

To measure mental health status, we relied on the K6 scale of Kessler et al.¹⁸ for nonspecific psychological distress. The K6 scale is a 6-item screening instrument widely used to assess mental illness in epidemiological studies. The screening instrument asked how often during the previous 30 days the respondent felt nervous, hopeless, worthless, so sad that nothing could cheer him or her up, restless or fidgety, and that everything was an effort. Using a 24-point scale, we defined adults scoring 0 to 4 points, 5 to 12 points, and 13 to 24 points as having no psychological distress (NPD), moderate psychological distress (MPD), and severe psychological distress (SPD), respectively.¹⁹

Study Outcomes

We compared 5 dimensions of health care access and health services utilization by immigration status and mental health status. Three measures of barriers to care due to cost were unmet medical care, unmet prescription medications, and unmet mental health care, all in the prior year. We also included 2 measures that assessed barriers to routine care: having no usual source of medical care that included a doctor’s office, a clinic, or health center, and reporting multiple emergency room (ER) visits in the prior year (which may be a source of care when an individual lacks a regular primary care provider). Of note, all measures analyzed in this study were self-reported, but these measures are regularly used to monitor access to health care in the United States.¹⁴

Statistical Analysis

We used descriptive statistics to characterize the study sample and to compare the differences between US-born and foreign-born individuals by mental health status. We then estimated multivariable logistic regression models comparing each outcome across 6 groups: US-born with no psychological distress, US-born with MPD, US-born with SPD, foreign-born with no psychological distress, foreign-born with MPD, and foreign-born with SPD; US-born adults with no psychological distress served as the reference group. All models adjusted for variables associated with health care access, including gender, age category (18–25, 26–34, 35–49, and 50–64 years), race/ethnicity (non-Hispanic White, non-Hispanic Black, non-Hispanic other races, Hispanic), educational attainment (less than high school, high school, some college, college graduate), relationship status (married, divorced or separated, widowed, never married), household income relative to the US Census Bureau’s poverty guidelines (≤ 100%, 100%–199%, 200%–399%, or ≥ 400% of federal poverty guidelines), health insurance status, self-rated health status (excellent, very good, good, poor or fair), number of chronic conditions (including cancer, hypertension, coronary heart disease, stroke, chronic obstructive pulmonary disease, asthma, diabetes, arthritis, hepatitis, and weak or failing kidneys), US Census region, and survey year. Follow-up regression models included interactions between immigration and mental health status to determine whether foreign-born adults were more or less likely to experience barriers to care compared with US-born adults of the same mental health status. We conducted analyses in Stata version 15 (StataCorp LP, College Station, TX) using survey weights and the SVY command to adjust standard errors for the complex survey design of the NHIS and to generate nationally representative estimates.²⁰ Results from all logistic regression models are presented as adjusted prevalence ratios with 95% confidence intervals. We calculated prevalence ratios using postestimation predictions at the mean value for each covariate with the MARGINS command in Stata. Hypothesis tests compared the value of each prevalence ratio to 1 using adjusted Wald tests to reflect the complex survey design. We also estimated prevalence ratios for models with interactions using predicted probabilities for all 6 possible combinations between immigration (foreign-born and US-born) and mental health status (NPD, MPD, and SPD) based on postestimation predictions at the mean value for each covariate.

RESULTS

Table 1 presents characteristics of nonelderly adults in the United States by immigration and mental health status. Approximately 18.1% and 4.1% of US-born adults reported moderate or severe psychological distress, respectively. US-born adults with MPD or SPD were more likely to be female, divorced or separated, never married, in low-income households, unemployed, uninsured, report poor or fair health, and have multiple chronic conditions compared with US-born adults with NPD. Age distributions and racial/ethnic composition across mental health categories were relatively similar for US-born adults. About 15.4% and 2.7% of foreign-born adults reported symptoms of moderate or severe psychological distress, respectively. Foreign-born adults with MPD or SPD were more likely to be female, Hispanic, divorced or separated, and from lower levels of educational attainment and family incomes. Foreign-born adults with MPD or SPD were also more likely to report poor or fair self-rated health and multiple chronic conditions compared with foreign-born adults with no psychological distress. Compared with their US-born counterparts, foreign-born adults were more likely to be racially and ethnically diverse, married, uninsured, and to have no chronic condition diagnoses. Foreign-born adults were also more likely to have lower education levels and to reside in low-income households compared with US-born adults.

TABLE 1—

Descriptive Statistics of Nonelderly Adults, by Mental Health and Immigration Status: National Health Interview Survey, United States, 2013–2016

	US-Born			Foreign-Born
	No Psychological Distress, No. or Weighted %	Moderate Psychological Distress, No. or Weighted %	Severe Psychological Distress, No. or Weighted %	No Psychological Distress, No. or Weighted %	Moderate Psychological Distress, No. or Weighted %	Severe Psychological Distress, No. or Weighted %
Sample size	62 628	15 785	3739	14 783	2926	567
Weighted %	77.8	18.1	4.1	82.0	15.4	2.7
Gender
Male	50.6	43.6	41.0	51.1	43.4	39.2
Female	49.4	56.5	59.0	48.9	56.6	60.9
Age, y
18–25	18.9	20.8	16.0	10.7	12.4	7.0
26–34	19.0	20.0	16.8	22.4	19.7	16.5
35–49	28.8	28.9	28.9	40.4	39.3	40.5
50–64	33.2	30.3	38.3	26.5	28.6	36.1
Race/ethnicity
Non-Hispanic White	73.9	72.3	71.2	17.0	19.3	15.4
Non-Hispanic Black	13.2	14.2	13.7	8.9	7.9	7.6
Hispanic	10.0	10.5	11.5	47.7	50.8	64.6
Non-Hispanic other	3.0	3.0	3.7	26.3	22.0	12.3
Relationship status
Married	52.8	40.2	32.7	66.6	58.1	52.1
Divorced/separated	12.5	17.9	26.9	9.9	14.6	22.8
Widowed	1.5	2.5	3.8	1.2	2.1	3.1
Never married	33.1	39.4	36.5	22.2	25.1	22.1
Missing data	0.2	0.1	0.2	0.2	0.1	0.0
Educational attainment
< high school	7.3	11.2	21.3	24.6	29.8	40.7
High school graduate	24.3	26.9	32.3	21.0	20.6	21.3
Some college	34.4	37.8	36.5	19.9	22.1	18.7
≥ bachelor’s degree	33.8	23.8	9.6	33.7	26.7	17.7
Missing data	0.2	0.3	0.4	0.9	0.7	1.7
Family income relative to poverty
≤ 100% FPG	9.7	18.3	33.1	16.2	22.2	36.0
100%–199% FPG	13.3	20.6	27.0	22.2	27.0	28.4
200%–399% FPG	26.6	27.7	21.1	25.6	24.7	19.0
≥ 400% FPG	43.5	28.2	14.3	28.5	20.3	10.4
Missing data	7.1	5.1	4.6	7.5	5.8	6.2
Health insurance status
Insured	88.5	83.9	79.9	72.2	67.8	66.0
Uninsured	10.9	15.5	19.6	27.4	31.5	33.2
Missing data	0.6	0.7	0.5	0.5	0.7	0.8
Health status
Excellent	34.9	19.2	7.8	35.9	20.4	15.1
Very good	35.5	29.3	14.6	31.4	25.7	14.1
Good	22.9	30.2	26.4	25.7	36.0	26.9
Poor/fair	6.7	21.3	51.2	7.1	17.9	43.9
Missing data	0.0	0.1	0.1	0.0	0.1	0.0
No. of chronic conditionsa
0	58.9	45.2	26.7	71.4	57.3	40.2
1	25.0	26.2	25.8	19.6	24.9	26.9
≥ 2	15.6	27.5	45.8	8.4	16.8	31.9
Missing data	0.4	1.1	1.7	0.6	1.0	1.0

Note. FPG = federal poverty guidelines (from US Census). Data are from the 2013–2016 National Health Interview Survey, adults aged 18–64 years.

^aChronic conditions include cancer, hypertension, coronary heart disease, stroke, chronic obstructive pulmonary disease, asthma, diabetes, arthritis, hepatitis, and weak or failing kidneys.

Table 2 presents prevalence estimates and logistic regression results on barriers to care by immigration and mental health status. On the basis of unadjusted prevalence estimates, US-born and foreign-born adults with MPD or SPD were significantly more likely to have no usual source of care, multiple ER visits, and unmet medical care, mental health care, and prescription medication needs due to cost compared with US-born adults with no psychological distress. There were no unadjusted differences in unmet health care needs between US-born and foreign-born adults with NPD. However, compared with US-born adults with NPD, foreign-born adults with NPD were more likely to have no usual source of care and less likely to have multiple ER visits.

TABLE 2—

Adjusted and Unadjusted Prevalence Ratios of Barriers to Care, by Immigration and Mental Health Status: National Health Interview Survey, United States, 2013–2016

	No Usual Source of Care		Multiple ER Visits		Unmet Medical Care Due to Cost		Unmet Mental Health Care Due to Cost		Unmet Prescription Medications Due to Cost
	Unadjusted Prevalence, %	Adjusted PR (95% CI)	Unadjusted Prevalence, %	Adjusted PR (95% CI)	Unadjusted Prevalence, %	Adjusted PR (95% CI)	Unadjusted Prevalence, %	Adjusted PR (95% CI)	Unadjusted Prevalence, %	Adjusted PR (95% CI)
US-born
No psychological distress	14.2	1 (Ref)	4.6	1 (Ref)	5.1	1 (Ref)	0.8	1 (Ref)	4.5	1 (Ref)
Moderate psychological distress	16.7	1.17 (1.09, 1.22)	13.7	1.80 (1.65, 1.95)	15.0	2.06 (1.90, 2.23)	6.0	5.43 (4.65, 6.21)	16.3	2.43 (2.24, 2.61)
Severe psychological distress	15.8	1.21 (1.05, 1.36)	28.6	2.63 (2.32, 2.95)	26.5	2.62 (2.34, 2.91)	20.8	16.27 (13.65, 18.87)	33.1	3.64 (3.25, 4.03)
Foreign-born
No psychological distress	23.7	1.25 (1.16, 1.35)	2.6	0.61 (0.52, 0.71)	5.3	0.84 (0.74, 0.94)	0.7	0.81 (0.57, 1.06)	4.4	0.78 (0.68, 0.88)
Moderate psychological distress	24.8	1.38 (1.20, 1.55)	7.0	1.07 (0.86, 1.28)	14.3	1.75 (1.48, 2.03)	3.1	2.77 (1.94, 3.60)	12.9	1.64 (1.36, 1.93)
Severe psychological distress	20.7	1.23 (0.91, 1.55)	19.5	2.18 (1.56, 2.81)	24.0	2.55 (1.90, 3.20)	13.2	10.35 (6.07, 14.64)	30.7	3.44 (2.50, 4.38)

Note. CI = confidence interval; ER = emergency room; PR = prevalence ratio. Data are from the 2013–2016 National Health Interview Survey, adults aged 18–64 years. Adjusted prevalence ratios are from logistic regression models controlling for gender, age category, race/ethnicity, educational attainment, marital status, household income relative to poverty, health insurance status, self-rated health status, no. of chronic conditions, US Census region, and survey year. Sampling weights were used when estimating prevalence and adjusted prevalence ratios.

Table 2 also presents results from multivariable logistic regression models that compared access to care by immigration and mental health status categories, with US-born adults with NPD used as the reference group. After we controlled for sociodemographic characteristics, US-born adults with moderate or severe psychological distress were more likely to have no usual source of care, multiple ER visits, and unmet medical, mental, and pharmaceutical care due to cost. After we controlled for sociodemographic characteristics, foreign-born adults with NPD were more likely to have no usual source of care and less likely to have multiple ER visits and unmet medical, prescription, or medication needs due to cost than their US-born counterparts with NPD. Finally, foreign-born adults with MPD or SPD were more likely to have unmet medical care needs, unmet mental health care needs, and unmet prescription medication needs compared with US-born adults with NPD. After we controlled for sociodemographic characteristics, foreign-born adults with MPD were more likely to have no usual source of care, and foreign-born adults with SPD were more likely to have multiple ER visits compared with US-born adults with NPD.

Table 3 presents regression adjusted results on barriers to care with interactions between immigration and mental health status. Overall, compared with US-born adults, foreign-born adults were less likely to report multiple ER visits and unmet medical care, mental health care, and prescription medications due to cost. Foreign-born adults with NPD and MPD, however, were more likely to have no usual source of care compared with their US-born counterparts with NPD and MPD.

TABLE 3—

Adjusted Prevalence Ratios of Barriers to Care, With Interactions Between Immigration and Mental Health Status: National Health Interview Survey, United States, 2013–2016

	No Usual Source of Care, Adjusted PR (95% CI)	Multiple ER Visits, Adjusted PR (95% CI)	Unmet Medical Care Due to Cost, Adjusted PR (95% CI)	Unmet Mental Health Care Due to Cost, Adjusted PR (95% CI)	Unmet Prescription Medications Due to Cost, Adjusted PR (95% CI)
Immigration status
US-born (Ref)	1	1	1	1	1
Foreign-born	1.23 (1.14, 1.32)	0.62 (0.54, 0.70)	0.85 (0.76, 0.94)	0.74 (0.55, 0.93)	0.77 (0.68, 0.86)
Mental health status
No psychological distress (NPD; Ref)	1	1	1	1	1
Moderate psychological distress (MPD)	1.16 (1.02, 1.29)	2.78 (2.46, 3.11)	2.70 (2.42, 2.97)	15.58 (13.09, 18.06)	3.77 (3.37, 4.16)
Severe psychological distress (SPD)	1.16 (1.09, 1.23)	1.79 (1.65, 1.93)	2.07 (1.92, 2.22)	4.99 (4.30, 5.67)	2.36 (2.20, 2.53)
Immigration status × mental health status
Foreign-born with NPD vs US-born with NPD	1.25 (1.16, 1.35)	0.61 (0.52, 0.71)	0.84 (0.74, 0.94)	0.81 (0.57, 1.06)	0.78 (0.68, 0.88)
Foreign-born with MPD vs US-born with MPD	1.18 (1.01, 1.34)	0.60 (0.47, 0.72)	0.85 (0.71, 0.99)	0.51 (0.37, 0.66)	0.68 (0.56, 0.80)
Foreign-born with SPD vs US-born with SPD	1.02 (0.72, 1.31)	0.83 (0.59, 1.07)	0.97 (0.72, 1.23)	0.64 (0.38, 0.90)	0.95 (0.68, 1.21)

Note. CI = confidence interval; ER = emergency room; PR = prevalence ratio. Data are from the 2013–2016 National Health Interview Survey, adults aged 18–64 years. Adjusted prevalence ratios are from logistic regression models controlling for gender, age category, race/ethnicity, educational attainment, marital status, household income relative to poverty, health insurance status, self-rated health status, no. of chronic conditions, US Census region, and survey year. Sampling weights were used when estimating adjusted prevalence ratios.

DISCUSSION

The size of the US immigrant population has increased over time and shows no signs of abating: the number of foreign-born individuals in the United States has more than quadrupled since 1965 and is expected to reach 78 million by 2065.²¹ Understanding the dynamics of immigrant health will help elucidate the effects on health patterns of both departing and receiving countries, including the overall health of the United States.^21,22 This analysis complements recent studies in the immigrant mental health literature that examined disparities in utilization between US-born and foreign-born populations. We found that both US-born and foreign-born adults with psychological distress experience wide barriers in care, particularly financial-related barriers to medical, mental health, and pharmaceutical care. Previous research has suggested that immigration status is a deterrent to mental health utilization in the United States. For example, prior studies have noted that immigrants are significantly less likely to take prescription drugs and that having no usual source of care is a major contributing factor for disparities between US-born and foreign-born groups’ utilization rates.²³ Conversely, our research suggests that individuals with psychological distress living in the United States have unmet health needs—including the ability to afford prescription drugs—irrespective of immigration status. Furthermore, in our study, foreign-born adults with NPD and MPD were much less likely to have a usual source of care compared with their US-born counterparts with NPD and MPD, respectively. These findings may be explained, in part, by a growing literature that suggests that it is not nativity per se that accounts for differences in immigrants’ health utilization but that the differences may be rooted in contextual and interpersonal circumstances among these groups, such as social support, community cohesion, or perceived discrimination.^23,24

Health care cost was a major barrier to care for both US-born and foreign-born adults with psychological distress. More research should identify best practices for improving access to routine and affordable medical care for adults living with psychological distress. Policymakers should prioritize the development of more affordable interventions that destigmatize treatment of mental illness. An emphasis on integrated care models and partnerships between primary care providers and psychiatrists for both immigrants and US-born adults, for example, would normalize the screening process of mental illness and create additional access points to target those in need. Heightened attention to mental health prevention services (such as depression and suicide screening) in primary care offices or emotional resilience training in schools may strengthen protective factors and allow for the early identification and treatment of mental illness. Similarly, community-based programs that improve mental health literacy and promote help seeking at the onset of symptoms can lead to early treatment and reduce the chance of subsequent episodes. For example, we recommend subsidizing cognitive behavior therapy as an early intervention method to prevent posttraumatic stress disorder for individuals at heightened risk for experiencing trauma.

Our research also suggests that both US-born and foreign-born adults with SPD were more likely to utilize ER services, even after we controlled for sociodemographic characteristics. Because health care costs prevent US-born and foreign-born adults from receiving necessary medical care, reducing costs to primary care and mental health services may also reduce the increased utilization of ERs, which tend to be more expensive visits. Policymakers and health care administrators should invest in programs that use ER visits as an opportunity to employ care-coordination models consisting of social services, mental health referrals, and pharmacist-conducted patient education. Investing in case managers who proactively identify patients that frequent the ER but have chronic and low-acuity mental health conditions or psychological distress should connect patients with available community providers to ensure longitudinal care.

Limitations

A limitation to using the NHIS is that all responses were self-reported, which can lead to response and recall bias when describing access to care. However, the health care access outcomes we examined are commonly used to monitor access to care in the United States.¹⁴ Additionally, reporting immigration status may be limited by selection bias. Prior research has explored different types of selection, including the “healthy immigrant effect” or “immigrant paradox” that may account for better health in immigrant populations compared with native-born populations.^25,26 Experiences of “double discrimination”—that is, prejudicial treatment based on a history of psychological distress and race/ethnicity—may prevent some foreign-born individuals with psychological distress from participating in the NHIS. Furthermore, for immigrants who are undocumented, fear of deportation or legal repercussions may also discourage participation in a formal research study. Moreover, the potential for reverse causality is not negligible, given the overlap between outcomes studied (the past year) and exposure of mental health status (the last 30 days). Ongoing longitudinal data would have allowed for a larger and more detailed examination of the relationship between psychological distress and health care access.

Another consideration when interpreting our results is the fact that the K6 is a screening tool, not a diagnostic instrument based on criteria from the Diagnostic and Statistical Manual of Mental Disorders. As a result, our psychological outcomes are self-reported data and not clinical diagnoses. Furthermore, research on the K6’s sensitivity to change with culturally diverse groups is needed. In a study that examined over 1000 articles utilizing the K6 scale, there was inconsistent evidence for its cultural appropriateness in clinic settings.²⁷ The lower prevalence of MSD and SPD reported by our foreign-born respondents may not be representative of each culturally diverse group and may inaccurately deflate this heterogonous group’s level of psychological distress. Caution should be exercised when interpreting K6 scores, and further research would benefit from the formulation of a psychological distress construct that includes culturally and linguistically diverse clients. Similarly, caution should also be exercised when generalizing the experience of all foreign-born adults, as aggregating immigrants into a single group may conceal variability within subgroups.²⁸

Another limitation to our analysis was a relatively small sample size of foreign-born adults compared with US-born adults. Because of the small number of foreign-born adults with severe psychological distress (2.7% of all foreign-born adults), we were reluctant to explore additional subgroup analysis such as method and duration of entry into the United States, or global region of birth. Furthermore, we were unable to stratify our results of immigrants on the basis of elective versus forced migration because this information was not collected. Because displaced persons and refugees are at higher risk for mental health disorders, our results may be biased to the extent that immigrants from this subset may be missing in the analysis.

Another marginalized group that was excluded is patients within the criminal justice system, including jails, prisons, and probation and parole settings, which are known to have an overrepresentation of mental illness.^29–33 One recent meta-analysis that evaluated 28 studies focusing on mental illness in US prisons found that the range of prevalence estimates for particular disorders was much greater in prisons than in community samples.³⁴ Unfortunately, this key cohort, which is more representative of the total population with mental illness, was excluded from our analysis. Other research should focus on how health outcomes vary among US- and foreign-born individuals within the prison and homeless populations to allow for a more representative sample of the mentally ill population.

Finally, because of the cross-sectional nature of this study, we can establish correlations but not pinpoint the causal mechanisms underlying the health care disparities for US-born and foreign-born groups. Unobserved variables—such as experiences of discrimination in employment or health care settings—are missing from our analysis and may explain the differences found in this study. Relatedly, the NHIS does not ascertain identity-specific reasons for barriers to care (e.g., care denied because of immigration status). Therefore, we cannot definitely establish the link between discrimination and barriers to care measured here, but ongoing research can help fill this research gap.

Conclusions

This study found substantial barriers to care for US-born and foreign-born adults living with psychological distress. Our results demonstrate a need for the development of treatment interventions that target adults living with psychological distress regardless of immigration status. We urge public health practitioners to continue to prioritize individuals living with psychological distress as a vulnerable and marginalized population. Additionally, more work is needed to investigate the specific biopsychosocial components that are protective against psychopathology, as well as the risk factors for psychiatric morbidity for individuals with psychological distress. High-quality, affordable medical and mental health care for the nation’s heterogeneous population will be achieved only if the health care and policy arenas jointly prioritize this endeavor.