Aging and Immigration Nexus: Health Ramifications for Older Adults with Undocumented Legal Status

Executive Summary

Families with undocumented immigration legal status[1] are a considerable part of the U.S. population. As these families remain longer in the U.S., the number of undocumented older adults grows. This makes it imperative to advance knowledge about the challenges and needs these aging adults face to inform policy, advocacy, and intervention efforts to reduce health, social, and economic risks in this historically marginalized population. In this report, we use a Social Determinants of Health (SDOH) lens to summarize existing research on compounded stressors and health risks that older adults with undocumented immigration legal status face in the U.S. — including financial instability, acculturative stress, discrimination and marginalization, disruption in family dynamics, and limited access to health care. We highlight the detrimental consequences of these stressors on the health and wellbeing of this group and make policy and advocacy recommendations. A multifaceted psychosocial approach to policy and advocacy is imperative to protect the wellbeing of this vulnerable immigrant population.

Introduction

Immigrants with undocumented legal status are foreign-born individuals who do not have a valid visa or other required immigration documentation to reside and/or work in the United States. There are over 10.5 million undocumented immigrants living in the U.S. and 5.9 million U.S.-born children living in mixed-status families, where one or both parents, siblings, or grandparents have an undocumented status. This makes families with undocumented status a significant proportion of the U.S. population (Guelespe et al. 2023). Despite recent mass arrivals of immigrants at the southern U.S.-Mexico border, the number of new immigrants with undocumented status arriving at the U.S. border has, in fact, declined since 2007. The decline has been particularly steep for those of Mexican origin, who used to be the largest ethnic group with undocumented status (Lopez et al. 2021). As new arrivals decline, existing families settled in the U.S. are naturally aging. Although most of the population with undocumented status is still comprised of young and middle-aged adults, approximately 10% are already over the age of 55 (Ayón et al. 2020). As this immigrant population ages, there is a critical need for humane policies focused on preventing harm, reducing economic impact, and protecting human rights.

Families with undocumented status face compounded social stressors that are detrimental to their health, wellbeing, and daily functioning. Within this population, older immigrants are particularly at risk. In addition to facing a high level of poverty and social disadvantage, older individuals face additional stressors. These include, for example, living with multiple chronic illnesses without access to health care, experiencing diminished occupational and functional abilities, and facing the loss of their loved ones at a distance (Ayón et al. 2020). They also face these stressors with limited support, inadequate or insufficient resources, and a lack of legal protection (Balakrishnan and Jordan 2019). Many have a life-long history of unaddressed trauma and live in constant fear of deportation and family separation, both of which are sources of stress (Garcini and Peña et al. 2017; Rabin et al. 2022). Research shows that the longer an immigrant resides in the U.S. without authorization, the greater their risk of experiencing diminished health and social outcomes, including increased risk of morbidity and mortality (Alegría et al. 2008).

When examining the health and social needs of older adults with undocumented status in the U.S., it is important to consider and understand how multiple compounded and chronic stressors combine to increase health risks for this vulnerable and marginalized immigrant population. The use of a Social Determinants of Health (SDOH) lens enables us to better focus on the systemic and social inequities that place this older population at risk. An SDOH approach examines the environments, conditions, and social structures that influence health risks (Maani and Galea 2020).

In this report, we summarize the five principal psychosocial stressors that increase health risk among older adults with undocumented status: 1) financial insecurity, 2) acculturative stress, 3) discrimination and marginalization, 4) disruption in family dynamics, and 5) limited access to health care in the face of frail health. Our study is informed by literature as well as lessons learned from our field studies with immigrant families residing near the U.S.-Mexico border. We also discuss the implications of these stressors on the health of older adults with undocumented status and provide advocacy and policy recommendations.

Psychosocial Stressors among Older Adults with Undocumented Status

Financial Insecurity

Economic stressors are common among immigrants with undocumented status, but they are particularly challenging for older people, many of whom experience a dramatic drop in income when they seek work that is physically less demanding than their previous positions in construction, agriculture, or housekeeping. Employment and financial challenges contribute to, and are compounded by, stressful changes in their perceived self-worth, life purpose, and sense of meaning (Ayón et al. 2020). For most immigrants with undocumented status, their work is a lifeline not only for themselves, but also for their families in the U.S. and abroad. When they are no longer able to perform jobs due to advancing age, their perceptions of themselves as caretakers, contributors, and family providers change. The fear of becoming a burden to their families magnifies. For those who continue to work in physically demanding jobs despite their age, work-related injuries are common, complicating their economic situation. Without proper access to health care their risk of morbidity and mortality increases (Ayón et al. 2020).

The poverty level for this group is estimated to be even more severe than that of their younger counterparts with undocumented status, which is at or below 138% of the federal poverty level (Ayón 2020; Flores Morales 2021). Unable to rely on social security, despite having contributed through payroll taxes, many are left living in poverty and uncertainty (Dang 2019). Lacking retirement plans and life savings, these individuals must often live day-to-day, having to rely on family members to meet their most basic needs — food, shelter, and caregiving — which complicates family dynamics and increases the financial instability of the family system.

In addition, despite having sent remittances to their families in their countries of origin for most of their lives, they do not receive pensions from their home countries. Those who return to their home countries or are deported often struggle to secure income and find employment. Many find themselves alone, as most of their families have relocated to the U.S. (Dang 2019). Overall, lack of accumulated wealth, financial insecurity from job and income loss, and costly health issues result in many living in poverty with increased food and housing insecurity, inability to access needed health care, and complicated family dynamics that threaten their primary source of social, emotional, instrumental, and economic support (Garcini and Daly et al. 2021).

Acculturative Stress

Acculturative stress is a salient stressor for many older adults with undocumented status, even those who have lived in the U.S. for a long time. Specifically, low literacy levels and limited English proficiency can make it difficult for them to adapt to life in the U.S., integrate into society, and build a sense of belonging. Most have a lower than high school education, some are unable to read or write, and many do not speak English (Brownell et al. 2016). Those of indigenous backgrounds, whose primary language is not Spanish, and other immigrants who do not speak their home country’s native language at are a particularly high risk of acculturative stress (Brownell et al. 2016). Many did not have the time or resources when they were younger to advance their education or to learn English, and instead prioritized work to meet the basic needs of their families (Brownell et al. 2016). Although recent trends in language proficiency are changing, with more recent waves of immigrants with undocumented status being proficient in English, the gap is becoming wider for older generations who do not speak English (Passel and Cohn 2019).

Low acculturation levels lead to difficulties in navigating life in the U.S. For instance, many of the population under study face challenges in navigating legal, financial, and health care services, meaning that they either avoid the use of such services or must rely on family members as cultural brokers (Flores Morales 2021). Limited English proficiency and literacy also increases risk of exploitation, and a relatively large number become victims of financial scams or fraud (Serafica et al. 2019). Additional stressors resulting from limited English proficiency include isolation, marginalization, and increased risk of discrimination (Serafica et al. 2019). To avoid the detrimental consequences associated with the language barrier, older adults with undocumented status often restrict their lives to the confines of the ethnic enclaves in which they live. Although protective to some extent, this can narrow these immigrants’ opportunities to access resources and information important for their health, wellbeing, and financial progress.

Discrimination and Marginalization

In recent years, anti-immigrant rhetoric and policies have led to increased discrimination against immigrants with undocumented status, with older immigrants being most at risk of the detrimental health and social effects of discrimination (Rabin et al. 2022). Prejudice that fuels stereotypes of older adults with undocumented status as burdensome to U.S. society, the economy, and the health care system, particularly when framed in the context of scarcity and competing resources, increases the profiling of such individuals and places them at risk for experiencing discrimination (Cobb et al. 2019). Harmful stereotyping fuels perceptions that these immigrants are undeserving of support and opportunities, thus contributing to systemic barriers that limit their access to health, social, financial, and legal resources (Garcia Quijano n.d). Anti-immigrant rhetoric and policies have also perpetuated feelings of “otherness” that contribute to marginalization and disenfranchisement (Ayón and Kiehne 2022; Buckingham and Angulo 2022). The anti-immigrant climate has stripped their sense of trust, safety, and security from many older people, leaving them unwilling to seek help even in emergency situations.

The detrimental physical and mental health effects of discrimination and marginalization have been documented, yet little is known about their compounded effects for older adults with undocumented status (Davis 2020). An individual may have multiple intersectional identities, and thus experience discrimination, stereotyping, and prejudice on several different bases. As well as ageism, discrimination can arise from having an undocumented immigration status, low acculturation, disability status, sexual or gender identities, and belonging to ethnic or racial groups that are the target of racism, such as immigrants of indigenous, Afro-Latino, Asian, or Middle-Eastern backgrounds. The more intersectional identities held by an older adult with undocumented status, the greater the risk for experiencing discrimination and its detrimental consequences, including diminished physical and mental health (Garcini et al. 2018).

Disruption in Family Dynamics

Changes in family dynamics resulting from financial instability, intergenerational gaps, frail health, and diminished functional ability are significant sources of stress for older adults with undocumented status (Ro et al. 2022). In Latino culture, a high emphasis is placed on preserving cohesion and positive interactions among family members, which is challenged when immigrant families face multiple stressors including poverty and ill health (Falzarano et al. 2022; Reich et al. 2020).

In a multigenerational household, the older family member with limited English proficiency often depends on younger and more acculturated members of the family to meet their health, social, and legal needs, which can increase stress within the family system (Garcini et al. 2021). Heightened reliance on family members as cultural brokers to navigate life in the U.S. can lead older adults to overcompensate or seek to repay their family for the help provided (Silverstein, Merril, and Attias-Donfut 2010). This situation complicates family dynamics, as older members of the household may feel compelled to take on additional tasks — such as caring for grandchildren while their adult children work — when they already have difficulty caring for themselves (Silverstein, Merril and Attias-Donfut 2010).

Family dynamics are further complicated when older adults need care, for example those with chronic illnesses that interfere with activities of daily living, like dementia and Alzheimer’s disease (Balbim et al. 2020). Given their precarious immigration status, financial difficulties, and cultural norms that discourage the delegation of caregiving for older family members to outsiders, role-renegotiation occurs, in which younger family members become the de facto caregivers of the household and are responsible for the wellbeing of aging family members (Balbim et al. 2020; Maldonado 2017). These situations may lead families to make difficult choices, such as prioritizing health care for certain family members to the detriment of others (e.g., children vs. grandparents), which may strain relationships, increase financial instability, and increase health risk for the older adults (Ayón et al. 2020). The additional stress from caregiving increases the risk of family rupture — divorce, people leaving home — and inadvertent neglect or abuse of older family members.

Transnational bereavement is another family stressor that affects the health and wellbeing of older adults with undocumented status. Losing a family member in their home country can be particularly distressing, as these individuals are unable to travel to be with their loved ones and must grieve from afar (Garcini et al. 2020). Transnational bereavement is often accompanied by sadness and guilt, which can remain long after the loss of a loved one (Garcini et al. 2020). Given the limited access to support and mental health services to help them cope with their loss, as well as the perceived stigma of mental health issues, these older immigrants often find themselves grieving alone and in silence. This increases their risk for experiencing complicated grief and its detrimental health and psychological consequences (Garcini et al. 2019).

Frail Health and Limited Access to Healthcare

Cumulative disadvantage and inequity over the course of life magnify the detrimental effects of compounded and chronic stressors on the physical and mental health of older adults with undocumented status (Ayón et al. 2020). Access to health care is limited because they are not eligible for services such as Medicaid, Medicare, Social Security, or retirement or disability services. In rare cases, when health care is available, for instance, through safety net providers, cost and fear prevent such people from seeking timely health services (Ayón et al. 2020; Garcini et al. 2022; Woofter and Sudhinaraset 2022). In many cases, they delay the use of health services, which results in deteriorated health and more advanced stages of disease when it may be too late to receive proper treatment (Ayón et al. 2020). Among this population fear that their personal information may be mishandled is a real concern that prevents them from seeking health services and potentially increases their — and their families’ — risk of detention (Garcini et al. 2022; Woofter and Sudhinaraset 2022). Concerns of discrimination due to undocumented legal status, limited literacy, and lack of English proficiency are additional barriers that limit access to health care (NAMI, n.d.; Woofter and Sudhinaraset 2022).

Other structural barriers to accessing health services for those with frail health include misinformation, disinformation, and the complexity of the health care system in general. For instance, many face significant problems with transportation, relying on family members to take them to medical appointments and to act as cultural brokers by facilitating communication with health providers (Woofter and Sudhinaraset 2022). Financial instability, lack of insurance, limited availability of translation services and bilingual providers, and limited cultural and contextual competence among providers are additional structural barriers that limit health care access (Jiménez-Rubio et al. 2020). A recent study found that it is common among frontline health care workers to feel ill-equipped to address the complex health needs of older adults with undocumented status given limited resources, inadequate training, and competing time demands (Yu et al. 2020).

This group also faces significant barriers to accessing mental health care. Limited information, misinformation, myths, and mental health stigma, all prevalent in immigrant communities, are significant barriers to mental health care access and utilization. Indeed, misinformation about mental illnesses and stigma about mental health treatments prevent many older adults with undocumented status from seeking mental health services that can facilitate healing and coping with life-long histories of compounded stress and trauma (Jiménez-Rubio et al. 2020). With these extra barriers to the use of mental health services, older immigrants are especially vulnerable to the physiological and psychological effects of trauma and stress, which may increase their risk for chronic physical and mental illnesses.

Effects of Chronic Psychosocial Stressors on the Health of Older Adults with Undocumented Status

Physical Health

Prior research has documented the detrimental physiological and psychological effects of compounded, chronic stress. Living under constant stress elevates the risk of morbidity and mortality, including accelerated aging, loss of functional ability, and cognitive decline such as Alzheimer’s disease and related dementia (Lavretsky and Newhouse 2012). A recent study found that twice as many older adults with undocumented status reported being in “fair or poor” health when compared to U.S.-born older adults, with only 29.3% of the immigrant group reporting “very good or excellent” health (Bustamante et al. 2022).

The psychosocial stressors highlighted above make older adults with undocumented status particularly vulnerable to chronic illnesses, age-related disorders, and mental illnesses (Jimenez-Rubio et al. 2020). Diabetes, hypertension, arthritis, chronic pain, and kidney failure are common illnesses among this group (Ayón 2019; Garcini et al. 2021). Additional health hazards include complications from infectious diseases due to their inability to access health services, which made this immigrant subgroup particularly vulnerable throughout the COVID-19 pandemic (Ayón 2019). When older people continue to work outside the home, work-related injuries are a constant threat to their health, including increased risk of disability and functional impairment (Bustamante et al. 2022).

Mental Health

Research shows that the cohort under study are at a high risk of diminished psychological wellbeing. For instance, those affected by financial instability exhibit increased rates of psychological distress, namely anxiety and depression (Chang 2019). Feelings of guilt and shame that undermine psychological health are also prevalent among this group due to their immigration status and their decreased ability to care for themselves. Unresolved guilt and shame can gradually reduce an immigrant’s willingness and ability to engage with society, thus contributing to feelings of isolation, loneliness, and lack of belonging (Brownell et al. 2016; Ward et al. 2018). This is concerning given the strong association between isolation and increased risk for dementia; a recent study showed a 28% increase in risk for dementia among adults living in social isolation when compared to those not socially isolated (Huang et al. 2023). In addition, complicated family dynamics contribute to increased anxiety, irritability, and depression among the subject population (Guo et al. 2015; Park et al. 2014).

Given their limited health care resources and access, older adults with undocumented status are often unable to meet their most basic physical and mental health needs, which aggravates their health status, magnifies their psychological symptoms of stress, and worsens existing psychosocial stressors — financial difficulties, family dynamics, caregiving needs, and marginalization (Balakrishnan and Jordan 2019; Morales 2021). This results in a cycle of cumulative disadvantage in which compounded stressors, past experiences of trauma and hardship, and existing social, economic, and legal inequities magnify the impact of social disadvantage and adversity on their health.

Policy Recommendations

Health — A Multifaceted Approach

A top priority should be focusing on policies that maintain the health of older adults with undocumented status and prevent diseases that can impair their functional ability, social wellbeing, and quality of life.

Because these individuals face many chronic stressors, multifaceted policy approaches are needed to reduce health risk and prevent further harm to this vulnerable and marginalized immigrant population. Reducing the economic burden of stress and age-related diseases on the individuals and their caregivers will also crucially lessen demands on the health care system, particularly emergency services and services provided by safety-net providers.

To reduce the burden of disease among older adults with undocumented status, their caregivers, and the health care system itself, policies that can facilitate access to health care services and resources are critical. At present, available emergency Medicaid services are fragmented and vary across states (Stanley, Lange-Maia, and Shah 2020). One way would be to expand the scope of health services provided by emergency Medicaid to include the treatment of complications for chronic conditions currently covered, as well as increase prevention efforts to facilitate timely diagnosis of chronic illnesses. However, to succeed this must be combined with policies making it safe for the target population to seek health services.

In 2020, changes were made to the public charge rule, providing that lawful immigrants who used social benefits could be disqualified from receiving permanent U.S. status — this deterred many from seeking health services, even in medical emergencies (Pillai and Artiga 2022). Although the language has since been amended to facilitate access in emergency situations, understandably mistrust and fear continue to deter immigrants with undocumented status from seeking health services. County health care programs are available to which the rule does not apply, so it is important to support and fund the dissemination of reliable information that reduces fear, builds trust, and motivates older immigrants to seek the services they need (Pillai and Artiga 2022).

Interventions at State Level

We recommend that policy and advocacy efforts be concentrated at the state level, since changing public policy at the federal level may be more challenging. Important areas for policy intervention include the following:

• Support and subsidies for nonprofit and community organizations that actively address the health needs of families with undocumented status, including older adults.
• Financial and structural support for building partnerships among nonprofits and local community organizations to coordinate, support, and facilitate preventative care and the treatment of chronic and acute illnesses along with the delivery of health information.
• In states with large populations with undocumented status, state-level policies for the continued financial support of safety-net providers and developing sliding scale financial assistance programs for older adults with undocumented status are fundamental to reduce the financial burden and ameliorate structural barriers that limit their access to health care.
• Fostering and protecting collaborative alliances between safety-net providers and nontraditional sources of service delivery that are trusted by the community — community health workers, faith-based organizations, grassroot organizations — can facilitate the delivery of physical and mental health services, resources, and information to the target population. This includes help with transportation, navigating health services, and overcoming the language barrier.
• In many cases, social service and community organizations that receive federal funding are mandated not to serve immigrants with undocumented status. These mandates need to be overturned.
• Finally, it is vital to train a medical and mental health care workforce that understands the complex needs of older adults with undocumented status, can provide culturally informed and contextually appropriate health services, and is large enough to cope with the demand (Ayón et al. 2020; Garcini, et al. 2023).

Access to Insurance

Prior research has emphasized the need for policies that facilitate health insurance through the public marketplace for older adults with undocumented status, which will require the dismantling of additional systemic barriers (Stanley, Lange-Maia, and Shah 2020). Although immigrants with undocumented status have the option to purchase private health insurance in the U.S., the high cost makes it unaffordable for many older people (Stanley, Lange-Maia, and Shah 2020). In addition to cost, difficulties navigating the complexities of health insurance policies, mistrust and fear due to the current anti-immigrant climate, and cultural preferences for living life in the present moment due to the uncertainty of having an undocumented status also deter immigrants with undocumented status from purchasing health insurance even if options become available (Stanley, Lange-Maia, and Shah 2020).

Policies need to overcome these barriers and encourage families with undocumented status to purchase and use health insurance, for both acute treatment and preventative care. Useful features would include:

• Support for free patient navigation programs that are culturally informed and appropriate to the lived experiences of immigrants with undocumented status.
• Increased safeguards in the confidentiality and protection of patients’ information.
• Insurance programs that incorporate financial incentives to reduce health care costs.

Policies to protect the health and wellbeing of the older population need to go beyond facilitating health care access and must also address other factors contributing to financial hardship, discrimination, marginalization, and abuse. This should include policies that seek to:

• Address basic needs, such as housing and food security — this can lessen the significant stressors associated with declining health among older adults with undocumented status (Chinchilla et al. 2022). Given the high prevalence of poverty among families with undocumented status, inclusive affordable housing ordinances that do not discriminate applicants based on documentation status can improve the availability of low-cost housing for families with undocumented status, particularly those with older family members (Dys et al. 2023; Chinchilla et al. 2022).
• Help counter food insecurity for those living in poverty — Supplemental Nutrition Assistance Programs (SNAPs) could be implemented in collaboration with local nonprofits and community organizations (Calvo and Waters 2023).
• Ensure the safe reporting of abuse and victimization of older adults with undocumented status, whether by employees, institutions, or family members, as well as enforcement policies to penalize the perpetrators and protect the victims.
• Finally, on a larger scale, comprehensive immigration reform is critical.

Conclusion

As the U.S. population with undocumented status continues to age, it is important for researchers, providers, policy makers, health care workers, and community advocates to focus on the voices and lived experiences of the community’s older adults. Studying the issues faced by older adults with undocumented status through a Social Determinants of Health (SDOH) lens enables us to examine the environments, conditions, and social structures that influence their health risks, giving context to the compounded, detrimental effect of these psychosocial stressors on this vulnerable population. As existing disparities increase and inequities grow, a multifaceted psychosocial approach to policy and advocacy is imperative to reduce health risk and prevent further harm to this marginalized group.

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Endnote

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[1] According to the new inclusive guidelines of the American Psychological Association (APA) it is no longer acceptable to say “undocumented immigrants” — instead we refer to “immigrants with undocumented [legal] status,” “people with undocumented status,” and so on. This new terminology is used frequently throughout the report to avoid unacceptable circumlocutions. See the “Person-First and Identity-First Language” section of the APA’s inclusive language guide (2nd ed), Equity, Diversity and Inclusion: https://www.apa.org/about/apa/equity-diversity-inclusion/language-guide.pdf. While it does not specifically mention legal status, the principle and rationale holds.

 

 

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