Proof of Citizenship at the Point of Care: Documentation Requests and Forgone Care Among California Immigrants, 2019-2022.

OBJECTIVE

To estimate how often immigrant adults are asked for a Social Security number or proof of citizenship to obtain care or enroll in school, who is asked for these documents, and whether being asked relates to health care access.

STUDY SETTING AND

DESIGN

Cross-sectional analysis of four pooled waves (2019-2022) of a population-based, multilingual survey of California adults. The exposure was the documentation request; outcomes were lacking a usual source of care and delaying or forgoing care.

DATA SOURCES AND ANALYTIC SAMPLE: California Health Interview Survey public-use files were used. The documentation item is asked only of foreign-born respondents, yielding 21,133 immigrant adults (15,313 naturalized, 5820 noncitizen). Survey-weighted logistic models with jackknife variance reported average marginal effects.

PRINCIPAL FINDINGS: Overall, 15.7% (95% CI: 14.9-16.5) reported being asked. After adjustment, noncitizens were 5.3 percentage points more likely than naturalized citizens (3.5-7.1) and limited-English-proficient adults 5.8 points more likely (3.5-8.1) to be asked. Being asked was associated with delaying or forgoing care (6.1 points; 4.2-8.0) but not with lacking a usual source of care (0.2 points; -1.9 to 2.3).

CONCLUSIONS

Documentation requests were common, concentrated among noncitizen and limited-English-proficient immigrants, and associated with forgone care. The cross-sectional design cannot establish causation.