Social Determinants of Immigrants’ Health in New York City: A Study of Six Neighborhoods in Brooklyn and Queens

Executive Summary

More than 3.1 million immigrants reside in New York City, comprising more than a third of the city’s total population. The boroughs of Brooklyn and Queens are home to nearly 940,000 and more than 1 million immigrants, respectively. According to the New York City Department of Health and Mental Hygiene’s (DOHMH) Community Health Survey (CHS), foreign-born New Yorkers have poorer health and less access to healthcare than their US-born counterparts.

For this study, the Center for Migration Studies of New York (CMS) focused on six neighborhoods in these two boroughs whose immigrant residents were identified by a previous CMS study, Virgin and Warren (2021), as most at risk of poor health outcomes:

Brooklyn

• Bay Ridge/Dyker Heights
• Bushwick
• Sunset Park/Windsor Terrace

Queens

• Elmhurst/South Corona
• Flushing/Whitestone/Murray Hill
• Jackson Heights/North Corona

Immigrants comprise between 31 to 63 percent and undocumented immigrants comprise between 5 to 18 percent of the total populations in these neighborhoods. Though many of New York City’s health and social service programs are open to all residents, immigrants – especially the undocumented – remain at greater risk of poor health outcomes than US-born residents due to other barriers to access to healthcare.

The CMS research team conducted a survey of 492 immigrants across these six neighborhoods and convened one focus group to collect data on immigrants’ health and well-being. CMS also surveyed 24 service providers including community health clinics, health-focused community-based organizations (CBOs), and hospitals that work with immigrants in the studied neighborhoods. Analysis of these data, together with the US Census Bureau’s American Community Survey (ACS) and the DOHMH’s CHS, provides insight into the factors that affect immigrants’ health and wellbeing across these neighborhoods. This study highlights several social determinants of health that likely contribute to the native-immigrant health gap. Finally, the study describes steps that can be taken to close this gap.

The report offers the following top-line findings:

Self-reported Health:

• Immigrant respondents on average said they were in good health. Respondents from Mexico, Hong Kong, and Bangladesh had the worst self-reported average health. Among the neighborhoods studied, immigrant respondents from Flushing/Whitestone/Murray Hill had the worst self-reported health.

Access to Care:

• Thirty-seven percent of immigrant respondents said they needed to access healthcare [1] in the last 12 months but did not receive it.
• Service providers identified different barriers than did immigrants to accessing healthcare for physical health concerns. The top three reasons immigrants said they did not receive the necessary physical healthcare were:

1. Lack of health insurance;
2. Inability to afford care; and
3. Inability to take time off due to work, childcare, or other responsibilities.

By contrast, the top three reasons immigrant service providers said immigrants did not receive needed physical healthcare were:

1. Language barriers;
2. Fear of revealing documentation status; and
3. Inability to afford services.

• These findings suggest that service providers overestimate the role culture plays as a barrier to immigrants receiving mental healthcare.
• The top three reasons immigrants reported for not seeking mental health services were:

1. Inability to take time off due to work, childcare, or other responsibilities;
2. Lack of health insurance; and
3. Inability to afford services.

By contrast, the top three reasons service providers said immigrants do not receive needed mental health services were:

1. Fear of stigma;
2. Cultural reasons; and
3. Language barriers.

Cost was one of the top deterrents for immigrants in seeking medical care. More than half of respondents said the out-of-pocket costs or high deductibles on their medical insurance plan “sometimes” or “regularly” discouraged them from seeking medical treatment. Twenty-nine percent of respondents said they had reduced spending on food or other essential items to cover the cost of healthcare in the previous year.

Income:

• Citizens, both US-born and naturalized, in New York City have much higher average earnings than legal noncitizens and undocumented immigrants. This large earnings gap between citizens and noncitizens held across the six neighborhoods with the exception of Elmhurst/South Corona, where the difference in earnings between citizens and noncitizens was smaller than in the other neighborhoods. Overall earnings for workers in Elmhurst/South Corona were the lowest of all the neighborhoods studied.

Occupation:

• Immigrant respondents who were exposed to mental and physical safety hazards at work were more likely to have a long-standing physical or mental illness.

Education:

• Immigrants with a lower level of education are less likely to have health insurance. While the gap in insurance coverage between the high- and low-educated is large among people of all immigration and citizenship statuses, it is especially pronounced among the undocumented. Between 2015 and 2019, 69 percent of undocumented immigrants in New York City with less than a 9th-grade education had no health insurance compared to 25 percent of undocumented college graduates.

Limited English Proficiency:

• More than 69 percent of immigrants who speak Spanish and more than 75 percent who speak Chinese [2] at home in the six neighborhoods have limited English proficiency.
• English language proficiency is associated with immigrants’ likelihood of seeking out needed care, but it was not reported as a primary barrier among immigrant respondents to receiving healthcare. Some immigrants – especially Cantonese-, Hindi-, and Mandarin speakers – reported language barriers to be a problem in accessing healthcare. Those immigrant groups, together with Urdu speakers, were the most likely to report discrimination on the basis of language when seeking care.
• Limited English proficiency may be a barrier to obtaining private health insurance, immigrants with limited English proficiency are more likely to use public health insurance or health insurance alternatives than remain uninsured.

Food Insecurity:

• Cost is the primary barrier which prevents immigrants from healthy eating. Nearly a quarter of immigrants across the six neighborhoods reported being food insecure (defined as going without eating at least once in the past month due to lack of resources) primarily due to a lack of funds to buy food, particularly healthy food.
• Immigrants living in Bushwick and Jackson Heights/North Corona are more likely to live in areas considered “food deserts,” or live in areas without access to fresh food within a mile of their house.
• Service providers reported lack of nearby fresh produce to be more of a barrier to healthy eating than did immigrants.

Neighborhood Conditions:

• Immigrants were asked about whether they felt safe in their neighborhoods and whether the following were problems in their neighborhood: access to public transportation, crime, lack of green spaces, litter, noise, pollution, and traffic. Better neighborhood quality along these metrics, was associated with better self-reported health among immigrants. Traffic was the top-reported problem overall across the neighborhoods, followed by noise, pollution, litter, and crime.
• Distance and lack of transportation were reported as barriers to accessing healthcare among immigrants in Bushwick, Elmhurst/South Corona, and Flushing/Whitestone/Murray Hill.

Discrimination:

• Immigrants reported facing discrimination in their communities, which sometimes prevented them from seeking healthcare. Among those who said they had needed to see a healthcare professional [3] in the previous 12 months but did not, 17 percent said fear of discrimination was one of the reasons they let their ailments go untreated.
• Discrimination on the basis of race in seeking healthcare was the form of discrimination most reported by immigrants, followed by discrimination based on nationality/citizenship.

Use of New York City Services:

• Approximately half of immigrant respondents had heard of NYC Care, a public program that provides low- to no-cost healthcare for residents who do not qualify or cannot afford health insurance. Just over a third of respondents had heard of the Mayor’s Office of Community Mental Health (formerly ThriveNYC), a city-led mental health service network, and ActionNYC, a city program providing free immigration legal service, regardless of status. About a quarter of respondents used NYC Care, and less than a fifth of respondents used ThriveNYC and ActionNYC. Those who used these programs were satisfied with them.

Based on these findings, CMS offers the following recommendations to improve immigrants’ health outcomes across the six neighborhoods studied:

• The Biden Administration should continue the marketplace provisions of the American Rescue Plan Act of 2021.[4] Part of this Act made Affordable Care Act (“Obamacare”) plans more affordable and expanded access to them by reducing the percentage of household income that people must spend on the benchmark for the plan and providing premium tax credits to households meeting more than 400 percent of the federal poverty level.
• Governor Hochul should ensure that New York State proposed legislation which includes “Coverage for All” is enacted. This bill [5] includes a budget of $345 million in funding for a program which would provide healthcare coverage for 150,000 low-income New Yorkers who currently cannot access health insurance due to immigration status.
• New York City Council should pass the pending bill, Int. No. 1674,[6] which would create an Office of the Patient Advocate within the DOHMH.
• New York City should fully fund NYC Care, including providing funding to CBOs to promote and enroll people in the program. Then, city agencies and mayoral offices (including the Office of Citywide Health Insurance Access at the New York City Human Resources Administration/Department of Social Services (HRA/DSS) and DOHMH), community health clinics, and health-focused and immigrant-serving CBOs should more actively promote NYC Care, ActionNYC, and the services of the Mayor’s Office of Community Mental Health (formerly ThriveNYC) in the six selected neighborhoods.
• Health service providers should ensure their personnel are racially, ethnically, and linguistically representative of the communities they serve and receive more training on diversity.
• Health service providers and CBOs that help to connect immigrants to health services and apply for health insurance should make their informational materials accessible to immigrants with a low or medium education level and should assist them with the application process.
• The New York City government should invest more in providing healthy, fresh food to immigrant New Yorkers, especially across the six neighborhoods.
• Health service providers and CBOs should provide additional outreach materials to immigrants from Bangladesh and Mexico across the six neighborhoods.
• The Office of Citywide Health Insurance Access at the HRA/DSS, DOHMH, health service providers, and community health clinics, should be paid for providing interpretation and translation services for and accompanying native speakers of certain Asian languages (including Cantonese, Hindi, Mandarin, and Urdu) as they access public services.
• Health service providers should increase the number of offices and clinics in Bushwick, Elmhurst/South Corona, and Flushing/Whitestone/Murray Hill.

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[1] “healthcare” refers to seeing a general practitioner, specialist doctor, dentist, or mental health professional, or using prescription or over-the-counter drugs.

[2] Mandarin or Cantonese.

[3] “healthcare professional” includes general practitioners, medical or surgical specialists, dentists, and mental health professionals.

[4] American Rescue Plan Act of 2021, H.R. Res. 1319, Pub. L. No. 117-2, 117th Cong. (2021) (enacted). https://www.congress.gov/117/plaws/publ2/PLAW-117publ2.pdf.

[5] S. Res. S1572A, Reg. Sess. (NY 2021-2022). https://www.nysenate.gov/legislation/bills/2021/s1572/amendment/a.

[6] Int. No. 1674, Reg. Sess. (NYC Council 2019). https://legistar.council.nyc.gov/LegislationDetailaspx?ID=4085833&GUID=C2FEBE38-2F3E-4908-8AB3-18394F115B67&Options=&Search=.