Joshua J. Fenton, BA

Nancy Moss, PhD

Heidi Ghattas Khalil, BS

Steven Asch, MD, MPH

A publication of the

Southern California Studies Center

University of Southern California

September 1996

& J. Fenton, N. Moss, H.G. Khalil, and S. Asch

The Southern California Studies Center (SC2) was established at the University of Southern California in the fall of 1995. The Center is a unique, campus-wide, interdisciplinary initiative. Its principal goal is to monitor and guide the transformations in environment, politics, economics, culture and society of Southern California. Both basic research and applied aspects of this mission are equally important. The Center has three fundamental objectives:

The combined energies that the Center assembles will give the University of Southern California significant roles as a premier repository of accessible regional data, a lead research center on regional issues, a cutting edge innovator of teaching technology, and a partner in collaborative leadership in community-building into the twenty-first century.

Southern California Studies Center

University of Southern California

3601 Watt Way, GFS 304A

Los Angeles, California 90089-1696

Telephone: (213) 740-5303

Fax: (213) 740-5302

n November 1994, a large majority of California voters passes Proposition 187, which would have made undocumented immigrants ineligible for a wide range of state-funded services, including most health services. Under Proposition 187, undocumented immigrants would have been eligible only for state-funded emergency medical services and services for some conditions deemed dangerous to the public health. The proposition would also have required health card providers to report suspected undocumented immigrants to the Immigration and Naturalization Service (INS).

Although the implementation of Proposition 187’s health provisions was immediately forestalled by legal challenges, its passage was followed by widespread anecdotal reports of decreases in the use of health serves and adverse clinical consequences following patient delays in seeking health care./ A recent case study performed in San Francisco County demonstrated a substantial decrease in the use of outpatient mental health services by young Hispanics following the election. The decline in outpatient service used by young Hispanics seems to have been followed by an increase in their use of crisis mental health services. Such reports raise concerns that the passage of Proposition 187 affected health service use across California despite the court injunction barring its implementation. Since the proposition targeted the predominately poor undocumented immigrant population,/ health clinics and hospitals serving low-income communities were likely sites of any decline in service that may have occurred after passage of Proposition 187. To date, however, we know of no systematic examinations of the statewide impact of the passage of Proposition 187 on the use of health services.

Questions regarding the impact of Proposition 187 remain salient despite a November1995 U.S. District Court decision that most of Proposition 187’s health provisions are unconstitutional. Proponents of the proposition have appealed the ruling, and California’s attorney general recently announced that the state intends to exclude undocumented women from state-funded prenatal care programs on the basis of Proposition 187. Moreover, similar measures are under consideration in other states with large immigrant populations, and members of the U.S. Congress and the California state legislature have proposed legislation that would even restrict the eligibility of legal immigrants for many health services./ While the implementation of such measures would clearly affect immigrants’ use of health services, even the perceived threat of such legislation alone could deter undocumented and documented immigrants from seeking health services. Meanwhile, many have voiced concern about the potentially deleterious fiscal and public health effects of denying immigrant groups health services.// Studies of how the passage of Proposition 187 may have affected the use of health services in California could yield important information regarding the potential effects on health service use and health outcomes of current legislative attempts to restrict immigrants’ eligibility for health services.

We surveyed the directors of a statewide representative sample of primary care medical clinics serving low-income populations in California to gather descriptive data regarding the effect of the passage of Proposition 187 on the use of primary care services. Our methods generated both quantitative data reflecting and qualitative date regarding the proposition’s impact on clinic visits and individual users of primary care services. Since the clinic sample is representative of clinics serving California’s low-income population, our data grant insight into the statewide impact of the passage of Proposition 187 on the use of primary care services.

We selected a weighted random sample of 145 clinics from the sampling frame. We weighted the sampling probability of each clinic by the annual number of patient visits recorded in the CPS database so that the clinics with larger number of annual patient visits had proportionally larger probabilities of inclusion in the sample. Because we sought a representative sample of clinics providing primary care medical services to predominately low-income patients, we excluded clinics if: 1) half or more of the clinic visits were for non-primary care medical services (e.g., dialysis, rehabilitation, mental health, substance abuse counseling); or 2) half or more of the clinic’s patients had private health insurance.

We administered separate instruments for mail survey and follow-up phone interview of the clinic directors between July and August 1995. The three-page mailed questionnaire contained close-ended items requesting data on: the clinic setting, the demographics of its patient population, and the types of clinical services provided; the total number of patient visits in the each month between October 1993-March 1994 and October 1994-March 1995; and the perceived effects of the passage of Proposition 187 on clinic service use. For example, each director was specifically asked: "Did you or your clinic staff notice any change in the number of patient visits after the passage of Proposition 187?"; and "Have you heard of any individual who delayed seeking care at your clinic due to fears related to Proposition 187". We also asked directors to characterize the trends in service for different ethnic groups and to estimate the duration of any perceived change in the number of patient visits.

After completion of the mailed questionnaire, trained interviewers conducted a semi-structured phone interview with each responding director, which we designed to elicit qualitative details regarding perceived effects of Proposition 187 on clinic patients and their use of services. Interviewers asked directors who were aware of an individual who delayed care: "Have you or your staff observed any clinical consequences related to individuals delaying services due to fears related to Proposition 187?" When recorded clinical details regarding perceived clinical consequences were unclear, one of the authors with medical training (S.A. or J.F.) called the clinic director to clarify the relationship between delays in care and perceived clinical consequences. A research assistant and one of the authors checked each returned survey for completeness and the validity of all responses. We corrected missing or invalid data by calling clinic directors and requesting correction.

Prior to analysis of clinic visit data, we standardized the total number of monthly visits at each clinic from October 1994 through March 1995 as a percent change relative to the same month in 1993-1994, which adjusted for clinic size and seasonal variation in clinic use. We then tested two hypotheses generated by directors’ survey responses regarding the election’s effect on clinic visits. Our first hypothesis was that the total number of visits to sampled clinics decreased in November 1994 relative to October. Our second hypothesis was the size of a clinic’s Latino population or the amount of maternal and child health services provided at a clinic predicted a decline in total visits in November relative to October. To test our first hypothesis, we compared the mean percent change in visits in November and October using the t-test (one-tailed). We tested our second hypothesis using multiple regression in which the dependent variable was the difference between the monthly mean percent changes in visits in November and October 1994 at each clinic. The independent variables in the model were the proportion of Latino patients and the proportion of maternal and child health services (a sum of the proportions of prenatal and obstetric, family planning, and pediatric services). Although we planned to test a model including both independent variables, high correlation between these variables (r=.56) made it impossible to determine their independent effects. We therefore selected the bivariate model that accounted for the greatest amount of variance. We planned to determine whether effects persisted into later months if statistically significant results were found in the November using the bivariate model. The residuals of predictive models were analyzed to detect influential data points, and final models were cross-validated with a randomly selected sample of half the clinics. Statistical analyses were conducted using the Statistical Analyses System software.

We conducted a qualitative thematic analysis of clinic directors’ phone interview responses. We identified trends in directors’ responses to interview questions and categorized responses by thematic content. Illustrative quotes or anecdotes were selected to highlight quantitative findings and recurrent themes of director’s responses. Qualitative and quantitative findings are presented together below.

f the 145 sampled clinics, 129 met our criteria for final inclusion in the survey. Of the 16 ineligible clinics, ten clinics provided predominately dental, mental, or substance abuse services, four clinics had closed, one clinic was a private practice serving mostly privately insured patients, and one was a children’s shelter. In the final sample of 129 clinics, 34 of 58 California counties were represented. The maximum number of sampled clinics in any one county was 32 (Los Angeles County). Although we sampled 29% of the clinics in the sampling frame, clinics in the final sample were the sites of 50% of the annual visits in 1990 to clinics in the sampling frame.

We obtained mail survey responses from 121 of the 129 eligible clinics (94%). Follow-up phone interviews were conducted with all but one director of the responding clinics. We obtained monthly visit data for 90 clinics (71%). After excluding data from two clinics with staffing or program changes, data for 88 clinics were available for analysis (68%). Clinics were directors did and did not provide total visit data were not significantly different with regard to setting, the ethnicities of their patient populations, types of clinical services provided, or the proportion where directors where directors perceived a decrease in total visits following the passage of Proposition 187.

The characteristics of the responding clinics are shown in Table 1. The clinics varied widely in terms of the ethnic composition of their patient populations, the clinical services provided, and the annual number of patient visits. Though many of the clinics served predominately White or African-American patients, most clinics served a substantial proportion of Latino patients. Similarly, a sizable proportion of patients at most clinics did not speak English as a primary language (45%). A very small fraction of most clinics’ patients were privately insured. Approximately one-third of the clinics were rural (36%). Most clinics were state-licensed not-for-profit community health centers (69%); the rest ere county-operated clinics based in communities or at county hospitals (data not shown).

Half of the clinic directors (51%) perceived a decrease in the number of patient visits after the passage of Proposition 187 (Table 2). Of these 62 clinic directors, nearly all (97%) specified that the number of visits by Latino patients decreased, while five directors (8%) believed the number of visits by Asians decreased as well. The median duration of the perceived decrease in patient visits was seven weeks, though seventeen directors (14%) indicated that the decrease in the number of visits persisted up to the time of the survey eight to nine months after the election.

In bi-variate analyses, the following clinic characteristic were associated with a perceived decrease in patient visits after the passage of Proposition 187: a greater proportion of Latino patients (p<0.01), a smaller proportion of Asian patients (p=.04), a greater proportion of prenatal and obstetric services (p<0.01), Los Angeles County (p=.04), and an urban setting (p=.05). Logistic regression analyses, however, revealed that only the proportion of Latino patients independently predicted a director’s perception of a decrease in total visits.

Directors who indicated a decrease in patient visits had varying perceptions of the magnitude of the decrease, as indicated by responses to open-ended questions. Though convinced that the passage of Proposition 187 frightened many clinic patients, some directors believed that few individuals were deterred from care due to fears related to Proposition 187. In contrast, other directors comments suggested larger, more sustained decreases in patient visits: "The day after the election … the waiting room was empty. We have four providers who are usually too busy to see everyone. For the weeks following the election, they weren’t busy at all. The were playing solitaire in their offices."

The monthly mean percent change in total visits in October and November 1994 did not differ significantly. Relative to the prior year, the mean percent changes in visits in October and November were 8.1% and 5.9% (p=.11, one-tailed). There was similar net growth in total visits in December 1994 through March 1995 (data not shown). In separate regression models, the proportion of Latino patients and the proportion of maternal and child health services were each statistically significant predictors of a decrease in visits in November relative to October (p<.05). However, the high correlation between these variables (r=.56) suggest that the variables represent the same underlying construct. A simple linear regression of the change in visits in November relative to October on the proportion of maternal and child health services was the most predictive model (R-square=.08). The coefficient for the proportion of maternal and child health services was –0.2 (p=.008), implying a relative decrease in visits of 2% for every 10% increment of a clinic’s maternal and child health services. The proportion of maternal and child health services did not significantly predict a decrease in total visits in December 1994 relative to October.

Over half of the clinic directors (51%) were aware of a patient who delayed receiving care due to fears related to Proposition 187, and nearly two-thirds of directors (65%) either knew of a patient who delayed care or perceived a decrease in total visits after the passage of Proposition 187 (Table 2). Of directors who were aware of individual delays in receiving care, nearly two-thirds (33% of responding clinics) knew of individuals who delayed receiving preventive health services, such as prenatal care, immunizations, tuberculosis screening or prophylaxis, and family planning services.

In Table 3, we have summarized recurrent themes of clinic directors’ responses to open-ended phone interview questions regarding patient delays in care. Directors’ responses clarified the type of services patients delayed and suggested reasons why patients may have delayed such services despite the court injunction barring implementation of the proposition. In particular, directors commonly noted marked initial decreases in the use of prenatal serviced by Latina women, and many were award of patients who delayed receiving care for minor acute illnesses or chronic conditions, such as hypertension, diabetes, and asthma. Almost universally, patients seemed to daily services due to a perceived risk of deportation. Patient fears of deportation seemed related in some cases to confusion regarding the legal status of the proposition or patients’ belief that Proposition 187 applied to both documented and undocumented immigrants.

Fourteen directors (12%) observed clinical consequences they believed could be attributed to patient delays in care due to fears related to Proposition 187 (Table 2). In eight of these cases, directors believed patients were either more sick than usual when they entered care or had suffered relatively minor consequences, such as worsened hypertension while temporarily without medications. However, six directors (5%) reported more serious clinical consequences of delays in care. Four of these incidents involved children whose parents presumably delayed bringing them to clinics for care. In three of these four cases, care was delayed for either asthma or diarrhea complicated by dehydration, resulting in two potentially preventable hospitalizations. In the fourth case, care was delayed for a young boy’s infected hand laceration, which ultimately required surgery at the nearest tertiary medical center.

Two directors witnessed serious complications of delays in care for adult patients, one of which resulted in a potentially avoidable death. In the first case, two undocumented men delayed care for nearly a month after sustaining bone fractures and lacerations in an accident that occurred soon after the election. The clinic director said: "They were afraid to see the doctor because they were afraid of Prop. 187 … They had just been drinking a lot to kill the pain." In the second case, a young Mexican immigrant died of septic shock after refusing in-hospital treatment for peri-rectal abscess. The director said: "Because of 187, he was afraid to go to an [emergency room] … and gave us the wrong name, wrong address, and wrong info [sic]. After we received the test results, we realized he was in danger, but we had no way to contact him … I feel that this death was directly attributable to the fear created by Prop. 187. If we could have gotten a hold of this individual sooner, this probably could have been prevented." As indicated by their statements, both clinic directors were convinced that patients’ fears of consequences related to Proposition 187 led to delays in care for fairly serious medical conditions.

Although a court injunction barred implementation of Prop. 187, two-thirds of directors of primary care clinics serving low-income populations in California believed the passage of the proposition affected their patients’ use of clinic services, manifested as either a decrease in the number of patient visits or individual patient delays in seeking care. Directors observed deterrent effects of the passage of Proposition 187 on individual patients for weeks to months following the election, and analysis of total visit data suggests that the passage of Proposition 187 may have been associated with a relative decrease in the use of maternal and child health services. Although the implementation of Proposition 187’s health provisions was immediately blocked by court order, our data suggest that the mere passage of Proposition 187 deterred some patients from seeking primary care services in California.

Our data suggest that the passage of Proposition 187 was associated with decreased use of preventive health services. In particular, clinics providing a greater proportion of maternal and child health services were more likely to have experienced a relative decrease in total visits after the election, and maternal and child health services are largely preventive in character (prenatal care, well-child checks and immunizations, and family planning services). In addition, one in three directors were aware of individual delays in receiving preventive health services, including childhood immunizations or care for tuberculosis. Although a relative decrease in the use of maternal and child health services could be explained by factors other than the passage of Proposition 187, patients in need of preventive health services after the election may have felt the risk of deportation or investigation by the INS was too great to justify seeking health services while feeling relatively well. Though most legislation restricting immigrants’ eligibility for health services would maintain eligibility for services deemed necessary to protect the public health and emergency services, it seems likely that many immigrants would avoid these services in the even such laws were implemented.

These findings are worrisome in light of a recent study of tuberculosis patients in Los Angeles County that showed that patients’ fear of immigration authorities deters some immigrants from seeking care long enough to expose many uninfected individuals. Given the higher rates of tuberculosis among immigrant compared to non-immigrant populations and lower immunization rates among poor and minority children, the implementation of legislation similar to Proposition 187 could pose the threat of epidemic infectious disease. Indeed, the continued provision of preventive health services to immigrant populations should remain a high priority for health planners and policymakers with the responsibility of preserving the public health. //

A majority clinic directors believed the passage of Proposition 187 deterred their patients use of primary care services, and many directors mentioned specific individual who of delayed receiving care for acute or chronic conditions that are usually amenable to treatment in a primary care setting, including hypertension, diabetes, asthma, and infectious diarrhea. // Indeed, several directors attributed clinical consequences to delays for such ambulatory-care sensitive conditions, including several potentially preventable hospitalizations. Although we detected no significant decrease in total primary care visits after the election, it nevertheless seems likely that Proposition 187 deterred some patients from seeking primary care services after the election. While it is conceivable that restricting immigrants’ access to some health services could reduce government health care expenditures, legislation that deters immigrants’ use of primary care services could increase health costs by eliminating the its cost-saving benefits, including reduced rates of preventable hospitalization.

Directors of clinics serving a higher proportion of Latino patients were more likely to have perceived an effect of the proposition on the use of clinic services, and the proportion of Latino clinic patients predicted a decrease in visits in the election months relative to the prior month. Given the campaign’s focus on undocumented immigrants from Mexico and Central America, Latino immigrants may have felt more distinctly threatened by the proposition than other immigrant groups. While we cannot exclude the possibility that non-Latino immigrants were also deterred from services, our data suggests that the passage of Proposition 187 had a particularly strong impact on the use of primary care services by Latino immigrants in California.

Half of directors were aware of patients who delayed care due to fears related to Proposition 187, and half cited a decrease in the number of patient visits of some duration after the election. If large percentages of clinic patients delayed care or delays were prolonged, the passage of Proposition 187 should have been temporarily associated with a sizeable decrease in the total number of visits to clinics in our sample. Our analysis, however, detected no significant decrease in total visits in November relative to October, and a clinic’s proportion of maternal and child health services accounted for only a small amount of the variance in the change in total visits in November relative to October. Together, these findings suggest that any effect of the election on total visits was probably small relative to other secular trends. Time-series analyses of visit data that is stratified by ethnicity could more accurately quantify the independent effect of passage of Proposition 187 on visits to California primary health care clinics.

A second limitation of our study is the reliance of much of our data on the perceptions of clinic directors. As patient advocates, directors may have been considerably biased with respect to the perceived effects of Proposition 187 on clinic patients. Nevertheless, our qualitative data represent the perspective of senior practitioners and managers on the front-lines of patient care and should be considered alongside future evidence. In addition, although our sample was comprehensive and our response rate high, we did not include several types of clinics in our sampling frame, including private physicians’ offices, tribal health clinics, and pediatric and obstetric and gynecology clinics operated by city, county, state, or federal governments, or in affiliation with medical training institutions. Our survey results, therefore, only generalize to primary care medial clinics serving low-income populations that provide a range of clinical services, including pediatrics, general adult medicine, and obstetrics/gynecology.

In summary, directors of primary care clinics serving low-income populations in California believed the passage of Proposition 187 had a deterrent effect on service use despite an immediate court injunction barring its implementation. Although total clinic visits did not significantly decrease after the election, our analysis suggests a relative decrease in the use of preventive services after the passage of Proposition 187. We therefore suspect that legislation basing eligibility for health services on immigration status would likely to deter immigrants from obtaining a range of basic health services. Beyond the likely deleterious effects on the health immigrant populations, restricting immigrants’ eligibility for basic health services could endanger the public health.