The rise in the number of Americans from ethnic minority backgrounds has been accompanied by an increased interest in disparities that characterize the health status and healthcare needs of the U.S. population. Much of the literature has focused on African Americans’ health disadvantages, which persist. Increasing interest also has been paid to the health of the Hispanic/Latino population, which currently is the largest minority population. Less attention has been paid to the health of the Asian-origin population, the fastest growing minority population, or to the Native American population.
This article presents an overview of current research and knowledge on health trends in middle-age and older people of ethnic-minority background in the United States, focusing primarily on ethnic differences in disability rates, which provide a useful global measure of the health of older people. We begin with a brief overview of mortality and life expectancy data that suggest a complex picture with unexpected and paradoxical findings.
Ethnic-Minority Status, Aging, and Mortality
Hummer and colleagues (2014) recently published an analysis and overview of mortality and longevity in non-Hispanic blacks, Hispanics/Latinos, Asian Americans, and Pacific Islanders, American Indians and Alaska Natives, and non-Hispanic whites. It shows that blacks experience considerably higher mortality rates than the general population. However, after age 85, their mortality rates drop below those of non-Hispanic whites. This evidence provides support for the long-observed (and debated) racial mortality crossover, which likely results from selective mortality earlier in life for blacks, and subsequent better health of African Americans living to very advanced ages. The latest evidence suggests the crossover is a birthcohort phenomenon, with more recent cohorts of African Americans less likely to experience a crossover in the future (Masters, 2012).
The evidence also strongly suggests a disadvantage in Native Americans, with respect to mortality, once we take into account misclassification of ethnicity on death certificates (Arias, 2010). Mortality rates for Hispanic/Latinos and Asian Americans, on the other hand, are lower than those for non-Hispanic whites and non-Hispanic blacks at every age (Hummer et al., 2014). While the Asian-origin advantage can be attributed to overall advantaged socioeconomic conditions, the Hispanic/Latino advantage has been considered paradoxical given the population’s overall socioeconomic disadvantage. The so-called Hispanic Paradox has been primarily attributed to a healthy migrant effect (Markides and Eschbach, 2011), which also is observed in other immigrant populations in the United States, as well as in Canada and Australia (Markides and Gerst, 2011).
Ethnic Minority Status, Aging, and Disability Rates
The first comprehensive attempt to examine race and ethnic differences in disability among Americans ages 65 and older was conducted by Markides and colleagues (2007), using 2000 United States Census data. The authors used several items intended to measure sensory disability (blindness, deafness, or a severe vision or hearing impairment); physical disability (a long-lasting condition that limits one or more basic activities); mental disability (difficulty learning, remembering, or concentrating); self-care disability (difficulty in dressing or bathing); and, going-outside-the-home disability (unable to shop or visit a doctor alone) (Stern, 2004). The relatively large sample size of the 2000 Census enabled data analysis on all major ethnic groups, including by type of Hispanic origin as well as by nativity status.
Older African Americans and Native Americans had the highest disability rates, followed by older Latinos. While we saw earlier that Hispanics enjoy a mortality advantage over other populations, they appear to be disadvantaged in disability rates compared to the non-Hispanic white older population. This translates into longer duration of disability and more dependency upon others for basic tasks in middle and late life compared to non-Hispanic whites. Also, there were differences observed by type of Hispanic origin. Puerto Ricans were the most disabled, followed by Mexican Americans, Dominicans, Central and South Americans, and Cuban Americans and Spaniards. The latter had rates similar to those of non-Hispanic whites. Given that approximately two thirds of all Hispanics/Latinos are of Mexican origin; the overall Hispanic rates are largely driven by the Mexican-origin population.
We have argued in previous research that the observed mortality and disability rates of the older Mexican-origin population in the United States reflect a new type of paradox that may be indicative of demographic processes (Markides and Eschbach, 2011). The population’s rising longevity in recent decades has been accompanied by increased disability rates, a phenomenon observed in the general United States population during the 1970s and early 1980s. The Mexican-origin population now may be at a similar stage in the epidemiologic transition, whereby rising longevity is accompanied by increasing comorbidity and disability in old age (Markides and Gerst, 2011).
This hypothesis is supported by data from the Hispanic Established Population for the Epidemiological Study of the Elderly, which showed increases in activities of daily living (ADL) disability rates among both Mexican American men and women ages 75 and older, from 1993 to 1994 and 2004 to 2005, in the Southwestern United States. These increases appear to be partly the result of increases in the prevalence of diabetes among Mexican Americans at advanced old age. In addition to increases in disability, increases in the prevalence of diabetes were accompanied by increases in the prevalence of cognitive impairment (Beard et al., 2009).
There also is some indication of a healthy immigrant effect in disability. The 2000 Census disability data supported a slight foreignborn advantage in older Hispanics as well as in Mexican-origin men, compared to their nativeborn counterparts. Such an advantage was absent among women. This adds support to the notion that older immigrant men were healthselected because they immigrated for occupational reasons, while older immigrant women were more likely to immigrate to be with their families (Markides et al., 2007). The data also showed that there is a foreign-born advantage among both African American men and women (Markides et al., 2007).
In a more recent analysis of these data, Elo, Mehta, and Huang (2011) documented a foreignborn disability advantage in blacks ages 25 and older. The advantage was greatest among those who were African-born, followed by non-Hispanic Caribbean-origin blacks. These data are consistent with the immigrant health selection hypothesis seen in other groups (Markides and Gerst, 2011). Findings also are consistent with accumulating evidence that there is a substantial mortality and life expectancy advantage among foreign-born blacks compared to U.S.-born blacks (Singh and Miller, 2004; Singh, Rodriguez-Lainz, and Kogan, 2013), including at ages 65 and older (Dupre, Gu, and Vaupel, 2012).
Adding to extant knowledge in this area, Mehta, Sudharsan, and Elo (2014) recently examined disability rates among older people in major race and the ethnic groups, using data from the National Health Interview Survey for 2000–2010. As in analyses reported above, they found an advantage among foreign-born Hispanics and African Americans over their native-born counterparts. However, the opposite was true for Asian Americans as previously reported by Mutchler, Prakash, and Burr (2007), using 2000 Census Public Use Microdata Sample data also used by Markides et al. (2007). Both analyses showed a native-born advantage among Asian-origin Americans, which is opposite to what has been found with other groups. However, this finding most likely is the result of compositional differences between the immigrant and native-born older Asian Americans: while more than half of foreign-born older Asian Americans are of Filipino, Vietnamese, or other less advantaged origins, most native-born older Asian Americans are of Japanese and Chinese origin, both among the most advantaged groups of older people in the United States (Markides et al., 2007; Mehta, Sudharsan, and Elo, 2014).
Disability trends, which can be used to project future disability rates, are especially relevant for public policy. Mehta, Sudharsan, and Elo (2014) found little evidence that the gap between black and white disability rates had closed between 2000 and 2010. However, they found evidence that the disadvantage of older Hispanic women relative to non-Hispanic women had worsened, possibly because of rising obesity rates among Hispanics, both native-born and immigrants (Singh et al., 2011). The authors state that rising obesity rates among all Americans must be monitored more carefully because of their negative influence on disability (Alley and Chang, 2007; Al Snih et al., 2007; Seeman et al., 2010), but especially on African Americans and Hispanics (Flegal et al., 2010).
Immigrant Status and Convergence to Native Levels
We noted earlier that foreign-born persons in the United States, Canada, and Australia have been found to enjoy a mortality advantage over their native-born counterparts. There is evidence that most immigrants arrive in relatively good health, but experience convergence to native health levels after ten to twenty years in the host country. Any health advantages disappear by the next generation, not only in mortality, but also in measures that include disability and other global self-reports. This convergence has been attributed to acculturative stress from linguistic and cultural isolation, as well as to changes in key health behaviors.
Antecol and Bedard (2006) used data from the United States National Health Interview Survey and found that immigrants to the United States arrive with significantly lower obesity rates than the native-born, as measured by the Body Mass Index (BMI). They found that women converge to native levels of BMI within ten years or so, while men close one-third of the gap within approximately fifteen years. As we suggested earlier, rising rates of obesity appear to contribute to high disability rates in middle and old age in most Hispanic groups, with the mortality advantage not translating into an advantage in disability and overall health. It has been suggested that convergence to native levels in obesity and other health indicators largely reflects changes in diet and physical activity accompanying the process of acculturation into the larger society (Antecol and Bedard, 2006; Mehta, Sudharsanan, and Elo, 2014).
We saw earlier that there is a sizeable disability advantage among foreign-born blacks over American-born blacks, with the advantage being the greatest among African immigrants followed by Caribbean-origin non-Hispanic blacks. Elo et al. (2011) found that the foreignborn advantage was higher at lower levels of schooling among non-Hispanic African- and Caribbean-origin immigrants, which also has been observed among Hispanics (Markides and Gerst, 2011; Turra and Goldman, 2007). Elo, Mehta, and Huang (2011) observed evidence of convergence in disability rates of black immigrants to native levels with time in the United States, which is consistent with the notion that immigrants adopt health behaviors and habits of the United States (Antecol and Bedard, 2006). Using data from the 1996–2010 Current Population Surveys, Hamilton and Hummer (2011) found that workingage Caribbean-origin blacks lose much of their health advantage vis-à-vis American-born blacks after approximately twenty years. On the other hand, African-born blacks maintain their advantage beyond twenty years. The authors conclude that black immigrants are selected for good health, as suggested by others (Elo, Mehta, and Huang, 2011; Hummer et al., 2014; Mehta, Sudharsanan, and Elo, 2014).
Data from Canada also support convergence to native levels in measures of physical health and disability. McDonald and Kennedy (2004) found that convergence in Canada reflected actual convergence in physical health rather than convergence in screening and diagnosis of pre-existing conditions associated with poor health and disability. Evidence of convergence also has been found in Australia (Biddle, Kennedy, and McDonald, 2007).
Underlying racial and ethnic disparities in health are socioeconomic disparities, as is the case among African Americans. Research also has focused on the role of discrimination and residential segregation, both of which are associated with unequal distribution of resources and access to healthcare (Mehta, Sudharsanan, and Elo, 2014). For similar reasons, one would expect that most Hispanic populations would also be disadvantaged in health status compared to the non-Hispanic white population. Yet evidence suggests a mortality advantage of Hispanics over non-Hispanic whites, despite their generally disadvantaged socioeconomic conditions. The Hispanic Epidemiologic Paradox has been attributed to immigrant health selection, which also is present among other immigrant groups in the United States (Akresh and Frank, 2008), as well as in Canada (McDonald and Kennedy, 2004), and Australia (Biddle, Kennedy, and McDonald, 2007).
The apparent mortality advantage of Hispanics over non-Hispanic whites does not appear to extend to disability and overall health (Hayward et al., 2014; Markides and Eschbach, 2011). This is particularly the case in the Mexican-origin population, which comprises approximately two-thirds of the overall Hispanic population. It appears that Mexican immigrants arrive in relatively good health but lose their advantage with time in the United States, partly because of acculturation factors and adoption of U.S. lifestyles (Antecol and Bedard, 2006; Gubernskaya, Bean, and Van Hook, 2013). At the same time, Mexican-origin immigrants work at physically demanding occupations and are negatively influenced by a lifetime of sub-standard medical care. Thus, by the time they reach old age, they actually appear to be more physically disabled than older non-Hispanic whites.
The loss of the health advantage of many immigrants by their middle and later years, partly because of poor access to medical care, has major policy implications, including immigration and healthcare reforms currently being debated at the national and regional levels.
Kyriakos S. Markides, Ph.D., is the Gnitzinger Professor of Aging Studies at the University of Texas Medical Branch in Galveston, Texas. He can be contacted at email@example.com. Sunshine Rote, Ph.D., is an assistant professor at the Kent School of Social Work, University of Louisville, in Louisville, Kentucky. She can be contacted at firstname.lastname@example.org.
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