How Does Satisfaction With Medical Care Differ by Citizenship and Nativity Status?: A County-Level Multilevel Analysis.
OBJECTIVE
This study examined patient satisfaction among community-dwelling older adults by their citizenship and nativity statuses. Since the welfare reform of 1996, citizenship has been an important factor in determining health care access among foreign-born individuals. Little is known regarding how the perceived satisfaction of older noncitizens compares with that of U.S.-born and naturalized citizens and how it is affected by county-level contextual characteristics.


METHODS
The 2000-2007 Medical Expenditure Panel Survey and linked Area Resource File were analyzed for 27,383 individuals (65+). Two dimensions of satisfaction (perceived access and ease of access) were examined using the Consumer Assessment of Health Plans Survey. Multilevel models were conducted using STATA.


RESULTS
After both individual- and county-level covariates were controlled for, noncitizens were less likely to agree that their providers had spent enough time with them (p = .03) or had sufficiently explained treatment (p = .01) compared with U.S.-born citizens. Noncitizens' overall ratings of their providers were also lower (p < .001). Among those reported needs, noncitizens reported greater difficulties in accessing acute care (p < .001), routine care (p < .001), and specialty care (p = .009). In these models, some county-level characteristics (e.g., % of foreign-born individuals) were negatively associated with individual-level satisfaction. Interestingly, noncitizens from counties with high densities of foreign-born populations had higher overall satisfaction levels than did their U.S.-born counterparts (i.e., interaction effect).


CONCLUSIONS
Guided by the expanded Andersen model, this study demonstrates the importance of considering both individual- and county-level contextual characteristics to accurately understand older noncitizens' access to health care and patient satisfaction.
College of Social Work, University of Tennessee, Knoxville. schoi12@utk.edu.
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D000368:Aged; D000369:Aged, 80 and over; D054242:Emigrants and Immigrants / Q000523:psychology* / Q000706:statistics & numerical data; D005260:Female; D019538:Health Care Surveys; D005102:Health Expenditures; D006296:Health Services / Q000706:statistics & numerical data*; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D054625:Healthcare Disparities / Q000208:ethnology*; D006801:Humans; D008297:Male; D055361:Multilevel Analysis; D017060:Patient Satisfaction; D010549:Personal Satisfaction; D044469:Racial Groups / Q000208:ethnology / Q000706:statistics & numerical data; D012111:Residence Characteristics; D012946:Social Welfare / Q000191:economics; D012959:Socioeconomic Factors; D014481:United States
Access to and utilization of services; Disparities (health, racial); Immigrants; Satisfaction