Healthcare Across the Pregnancy Continuum: Nativity-Based Analysis of Medical Expenditures Among U.S.-Born, Recent Arrivals, and Established Immigrant Women

Abstract

By 2021, over 13% of the U.S. population was foreign-born, totaling approximately 45 million people. Immigrants generally have lower per capita healthcare expenditures than U.S.-born natives. However, pregnancy-related healthcare use and costs increases among immigrant women, accounting for a substantial share of medical spending for immigrants. This dissertation examines how immigrant status influence perinatal healthcare expenditures, and investigates the expenditures among immigrants disaggregated by recent arrivals (<5 years) and established immigrants (≥5 years) within the context of Medicaid coverage policy for immigrants. Using 2013-2015 nationally representative MEPS data, we studied the concordance between self-reported and diagnosis-based pregnancy indicators, reporting the performance metrics of the logit and machine learning models. Findings suggest high concordance between the self-reported and diagnosis-based pregnancy indicators for uncomplicated pregnancies. However, there are inconsistencies in pregnancy status. The diagnosis-based indicator was more likely to miss recent arrivals who self-reported as pregnant, suggesting studies that only use diagnosis-based variables to study the pregnant population may undercount immigrants, particularly recent arrivals. Next, using linked 2013-2016 MEPS person-level, Medical Conditions, and Event-level datasets, we investigated the association between immigrant status and healthcare expenditures in various healthcare settings among pregnant women. Results showed that the odds of pregnant established immigrants having a positive inpatient expenditure was 1.73 times higher than pregnant U.S.-born women. However, when they had positive expenditures in the inpatient setting, established immigrants spent significantly less than U.S.-born women. Findings suggest lower expenditures among established immigrants may indicate unmet healthcare needs rather than cost savings. Lastly, we developed an algorithm to identify perinatal women with recent births and examined the association between immigrant status and healthcare expenditures across various healthcare settings. Differences between recent arrivals and established immigrants showed, on average, recent arrivals spent more in the inpatient setting, at $6,910.71 (CI: $875.72 - $12,925.70; p-value = 0.024) and less for office based visits, at -$1,581.93 (CI: -$3,105.46 – -$58.40; p-value = 0.042) compared to established immigrants. The results suggest recent immigrants may underutilize primary care during the prenatal period. Our findings indicate that aggregating immigrants into a single group could mask the heterogeneity of perinatal expenditures among immigrants.