Columbia University School of Public Health
Dissertation Title: "Improving Migrant Health Policies and Programs: From the Normative to the Positive"
As the population of migrants continues to grow, ensuring migrant health needs are met is a global-public health priority. This dissertation examines health policies and programs that impact migrant health to improve upon them and mitigate disparities. The focus is on Mexican citizens, immigrants in California and elderly immigrant populations in the U.S., since they represent a large share of immigrants with increasing health needs in this country and the world. To do so, I draw from an interdisciplinary approach to health policy investigation at the intersection of ethics, health services research and implementation science. I use normative, quantitative and qualitative methods to analyze these policies.
Paper 1 examines if the Mexican constitutional right to health care extends beyond the states borders and if the Mexican government has a duty to protect the health of its citizens abroad. Through an account that focuses on the feasibility of Mexican migrant health policies, we first present examples from guiding policy documents and published articles that imply the Mexican constitutional right to health extends beyond the border. The main claim is that the Mexican constitutional right to health care can only exist inside Mexico’s borders because a state can only feasibly control what healthcare people have access to inside their state and lacks the authority to control another country’s health policies. We argue that this does not rid the Mexican government of a responsibility to protect the health of citizens abroad with the resources it can control. Thus, to meet the health needs of Mexican citizens abroad fairly, the Mexican Migrant Health Program and related policies such as providing monetary compensation for would-be entitlements abroad require justifications and limits. Instituting a fair and deliberative priority setting process is recommended as a step that adds legitimacy to the Mexican Migrant Health program and related policies.
Paper 2 investigates the effects of the ACA’s coverage expansion among immigrant groups of differing legal status in California – the state with the largest foreign born population. Using data from the California Health Interview Survey (2003-2016), we compare changes in health coverage and access to care among immigrants in California before and after implementation of the ACA. We find that the ACA has led to major gains in coverage for lawful permanent residents in California, similar in scope to changes among citizens. However, unauthorized immigrants have experienced only modest increases in coverage, with the result disparity in uninsured rates for this group relative to citizens and permanent residents widening considerably since 2014. Findings indicate a significant increase in having a usual source of care across all groups, but without a significant change in disparities for this outcome. Our results have important implications for the intersection of health policy, immigration, and health equity.
Paper 3 explores how to facilitate the adoption of a successful evidence-based intervention to reduce mental illness and physical disability for minority elders in community based organizations (CBOs). CBOs provide preventive programs to serve a wide array of minority elders. Yet, they are constantly underfunded and understaffed, with limited capacity to expand services. A survey with 30 CBO staff, 4 focus groups, and 20 in-depth interviews were conducted to examine staff perspectives about the intervention, and factors that need to be addressed to facilitate its adoption. The participants identified better payment and levels of workload as factors that can foster motivation, self-efficacy and retain staff to provide the intervention. Capacity building strategies such as identifying committed staff who can provide a ‘train the trainer’ model and adapting training tools appeared as a priority to ensure adoption of the intervention. Adapting the intervention to include strategies that can overcome financial obstacles also emerged as a recommendation. Our work suggests that staff that presented the Positive Minds – Strong Bodies (PM-SB) offer important insights on how to adapt the intervention for implementation. Including the perceptions of staff that provide evidence based interventions (EBIs) in CBOs can facilitate the transition from a research trial to a scalable implementation.