COMMENTARIES
Are Latino Immigrants a Burden to Safety Net Services in Nontraditional
Immigrant States? Lessons From Oregon
The significant growth of
the Latino population in the
midst of an economic reces-
sion has invigorated anti-
Latino, anti-immigrant sen-
timents in many US states.
One common misconception
is that Latino immigrants are
a burden to safety net ser-
vices. This may be particu-
larly true in nontraditional
immigrant states that have
not historically served La-
tino immigrants.
Oregon data suggest that
despite a higher prevalence
of poverty, use of safety net
services among Latino im-
migrants in Oregon is lower
than that among non-Latino
Whites. Immigration status,
costs, lack of insurance cov-
erage, and discrimination are
among the reasons for this
group’s limited use of ser-
vices.
Nevertheless, policies de-
signed to strengthen commu-
nity and institutional support
for Latino immigrant families
should be considered in the
context of current health care
and immigration reform ef-
forts. (Am J Public Health.
2014;104:781–786. doi:10.
2105/AJPH.2013.301862)
May 2014, Vol 104, No. 5 | American Journal of Public Health
Daniel López-Cevallos, PhD, MPH
RECENT CENSUS DATA CON-
firmed Latinos as the new “majority
minority” in the United States, ac-
counting for 16% of the US pop-
ulation.1 Although more than half
of the Latino population lives in
traditional gateway states (Califor-
nia, Texas, Florida, New York,
Illinois), nontraditional immigrant
states have seen significantly higher
increases in numbers of Latino
residents. For instance, although
the Latino population increased by
“only” 31% in California between
2000 and 2011, it increased by
70% in Oregon, 100% in Wash-
ington, and 154% in South Caro-
lina during the same period.2
This significant growth has
brought a renewed wave of anti-
immigrant (which could also be
characterized as anti-Latino) senti-
ment (sometimes translated into
legislation) in a number of non-
traditional immigrant states.3,4 The
Border Security, Economic Oppor-
tunity, and Immigration Moderni-
zation Act (S.744) passed by the US
Senate, and currently in discussion
in the US House of Representa-
tives, has only heightened public
sensibilities by reaffirming the need
to first “secure the US---Mexico
border” before granting a path to
legal status for 11 million undocu-
mented immigrants.
LATINOS IN OREGON
Table 1 shows a profile of the
Latino population in Oregon,
distinguishing US-born from
foreign-born (or immigrant) individ-
uals and comparing both with non-
Latino Whites. In compiling these
data, we used Pew Hispanic Center
state-specific tabulations from the
2007 American Community Sur-
vey because they provided a fairly
comprehensive sociodemographic
profile of this population. Although
2 of every 3 foreign-born Latinos in
Oregon have less than a high school
education, their unemployment rate
is lower than that of US-born Lati-
nos and non-Latino Whites. The
educational achievement of
US-born Latinos is slightly below
that of non-Latino Whites but is
much better than that of foreign-
born Latinos.
However, educational attainment
among US-born Latinos has not
necessarily translated into economic
achievement. When employed in
full-time, year-round work, they
make 80% of the earnings of White
workers with comparable educa-
tion. Unemployment and poverty
rates among US-born Latinos youn-
ger than 64 years are twice those of
the White population.
Nearly 1 in 10 immigrant fam-
ilies in the United States include
members who are of mixed status,
with one or both parents being
noncitizens and one or more chil-
dren being citizens.5 These non-
citizen parents are probably re-
luctant to approach publicly
funded institutions for services for
their US-born children. Barriers to
accessing services may include
language, misconceptions regard-
ing immigration law, fear of de-
portation and family separation,
costs, and discrimination.6,7 As
a result, children of immigrants
use public benefits less often than
other children, despite their higher
López-Cevallos | Peer Reviewed | Commentaries | 781
poverty rates.8 Data from the
2000 census show that although
Mexican-born immigrants have
higher poverty rates (28% vs
11%) and higher labor force par-
ticipation (71% vs 65%), their use
of public assistance is 2%, a simi-
lar percentage to that of US-born
Oregonians (the 2010 census did
not include these data for the
foreign-born population).
ARE LATINOS A BURDEN
TO SAFETY NET
SERVICES?
Our politics at its best involves us
recognizing ourselves in each
other. And our politics at its worst
is when we see immigrants or
women or blacks or gays or
Mexicans as somehow separate,
apart from us. (Barack Obama,
October 29, 20069)
“Politics at its worst” may very
well summarize the immigration
and safety net reform debates of the
recent and not so recent past.10,11 A
recent example is the now infamous
“You lie!” interjection that a US
representative shouted when Presi-
dent Obama pointed out that his
Affordable Care Act “would not
apply to those who are here
illegally.”10(p422) The contentious
and in a way restrictionist per-
spective that refers to the so-called
burden that recent immigrants
(Latinos in particular) place on US
society is not new.12 In fact, it has
been used in the past against
waves of European and Asian
immigrants.13,14 Public policy
has focused its attention on the par-
ticipation of immigrants in a variety
of social, health, and education
programs paid for with tax dollars.
 COMMENTARIES

Various legislative proposals

TABLE 1—Selected Characteristics of Latino and Non-Latino Households: Oregon, 2007 that would deny publicly funded
Latino services to immigrants have sur-
Characteristic All Non-Latino White All US-Born Foreign-Born faced at both the federal and state
levels.10After the enactment of the
Population (thousands), no. (%) 3747.5 (100.0) 3014.9 (80.5) 391.6 (10.4) 213.1 (5.7) 178.4 (4.8) Personal Responsibility and Work
Female, % 50.5 51.0 45.0 47.8 41.7 Opportunity Reconciliation Act
Age group, y, % (110 Stat 2105) in 1996, Con-
<5 6.2 5.2 12.5 22.2 0.9 gress barred undocumented im-
5–17 16.8 14.9 25.8 39.4 9.5 migrants from receiving any form
18–29 16.2 15.4 21.0 16.5 26.4 of public assistance with the ex-
30–39 13.8 12.8 20.2 8.7 33.9 ception of emergency Medicaid.15
40–49 14.2 14.8 10.4 5.7 16.0 Both health care and immigration
50–64 19.7 21.8 7.1 5.3 9.2 reform efforts under the Obama
‡ 65 13.1 15.1 3.1 2.2 4.1 administration have continued
School enrollment (aged 5–18 y), % 96.2 96.7 94.1 93.9 . . .a with this policy. Moreover, even
Educational attainment (aged ‡ 25 y), % documented immigrants who ar-
< high school 12.0 8.4 49.0 15.3 63.5 rived in the United States after
High school or equivalent 27.8 28.4 24.5 29.2 22.5 August 22, 1996, are not eligible
Some college 31.7 33.4 15.5 32.4 8.2 for federally funded Temporary
‡ bachelor’s degree 28.5 29.8 11.0 23.1 5.8 Assistance for Needy Families
Unemployment rate,b % 6.5 6.3 7.3 12.6 4.7 (TANF), Medicaid, or State Chil-
Median annual personal earnings, $ dren’s Health Insurance Program
Totalc 25 298 28 333 18 214 20 238 17 202 benefits during their first 5 years
Full-time, year-round workers 37 946 40 476 23 071 32 381 20 238 in the country.
Median annual household income, $ 48 571 50 595 37 643 46 548 34 405 The Personal Responsibility
Living in poverty, by age group, y, % and Work Opportunity Reconcili-
< 18 16.4 12.9 29.1 27.5 40.1 ation Act also dropped eligibility
18–64 11.3 10.0 17.1 17.5 16.9 for food stamps (now referred to
‡ 65 8.1 7.5 6.9 6.1 7.3 as the Supplemental Nutrition
Citizenship status, % Assistance Program) among docu-
Citizen 93.6 98.6 62.2 100.0 17.1 mented immigrant adults, regard-
Noncitizen 6.4 1.4 37.8 0.0 82.9 less of date of entry, until they
Only English spoken at home,d % naturalized or proved that they,
Yes 80.2 90.4 19.6 33.4 3.1 their spouse, or their parents were
No 13.6 4.4 67.9 44.4 96.1 employed in the United States for
English-language proficiency,d % a combined total of at least 10
Speaks English very well 7.3 3.2 30.0 34.9 24.2 years.6 Although food stamps for
Speaks English less than very well 6.3 1.2 37.9 9.5 71.9 children, disabled individuals, and
Latino origin, % older adults have subsequently
Mexican ... ... 82.8 79.5 86.8 been restored, working-age immi-
Other Hispanic ... ... 17.2 20.5 13.2 grants remain ineligible. Between
Year of entry, % 1994 and 1999, documented
Before 1990 ... ... ... ... 32.6 immigrants’ use of welfare benefits
1990–1999 ... ... ... ... 36.6 declined significantly (TANF by
2000 or later ... ... ... ... 30.8 60%, food stamps by 48%, Social
Source. Data are 2007 Pew Hispanic Center tabulations (see http://pewhispanic.org/states/?stateid=OR). Security insurance by 32%, and
a
Insufficient number of observations to provide a reliable estimate. Medicaid by 15%).16,17 According
b
For civilians aged ‡ 16 years. to Fix and Passel,16 the decline was
c
For persons aged ‡ 16 years with earnings.
d
For persons aged ‡ 5 years. not accounted for by an increase
in the number of naturalizations
or by rising incomes within immi-
grant families.

782 | Commentaries | Peer Reviewed | López-Cevallos American Journal of Public Health | May 2014, Vol 104, No. 5

Relative to children in US-born
families, children who are not
citizens or who have foreign-born
parents are at greater risk for
being uninsured, not visiting
a physician in the past year for
acute or chronic conditions, and
having limited opportunities to
receive preventive health care
services.18 Policy changes resulting
from 1996 welfare and immigra-
tion reforms have increased food
insecurity15 and lack of insurance
coverage among immigrant chil-
dren.19,20 Children of immigrants
make less use of medical emer-
gency units than their White and
African American counterparts.21
In comparison with the general US
population, foreign-born individ-
uals use fewer medical services
and contribute less to health care
costs in relation to their population
share. Although they make up
3.2% of the US population, un-
authorized adult immigrants ac-
count for only 1.5% of US medical
costs. This gap is probably related
to factors such as prohibitive
costs, lack of health insurance,
discrimination, mistrust, and fear of
deportation.22---24
Recent studies show that, even
when immigrants are insured,
their per capita medical expendi-
tures are lower than those of
US-born individuals.25,26 Ku25
found that recent immigrants were
responsible for only about 1% of
public medical expenditures, even
though they account for approxi-
mately 5% of the US population.
After socioeconomic and other
factors had been taken into ac-
count, immigrants’ medical costs
averaged about 14% to 20% less
than those among US-born indi-
viduals. This suggests that immi-
grants’ insurance premiums may
be cross-subsidizing care for the
US-born population.25
Treatment of unauthorized
immigrants may contribute to
May 2014, Vol 104, No. 5 | American Journal of Public Health
COMMENTARIES
uncompensated care costs, but
the main reason such costs are
increasing is the rise in the number
of people who lack health insur-
ance coverage.27,28 A study
examining trends in health expen-
ditures between 1999 and 2006
showed that expenditures for
noncitizens were not a growing
problem; on average, they were
50% lower than expenditures
for US-born individuals.29 Nev-
ertheless, current health insur-
ance reform efforts have limited
immigrants’ access to health
insurance.10,23,30 Another recent
study showed that, between 2002
and 2009, immigrants had a net
contribution of $115.2 billion to the
Medicare Trust Fund (i.e., they
contributed more than what they
consumed). By contrast, US-born
individuals had a net contribution
of –$28.1 billion (i.e., they con-
sumed more than what they con-
tributed).31
In Oregon, uncompensated
hospital care costs increased from
roughly $130 million to $722
million from 1996 to 2006.32
Notably, however, uncompen-
sated care costs decreased be-
tween 1994, the year the Oregon
Health Plan was created, and
2002, the final year of open en-
rollment in the plan. In turn, sub-
sequent reductions in enrollments
have led to increases in uncom-
pensated care.27 Another study
showed that there is no significant
relationship between uncompen-
sated care expenditures and states’
percentages of noncitizen immi-
grants.33 According to Castel
et al.,33 lack of insurance coverage
is the only significant factor pre-
dicting uncompensated hospital
care expenditures. According to
a more recent study, there is no
evidence to support the frequent
claims that uninsured adult pa-
tients are a primary cause of
emergency room overcrowding,
present with less acute conditions
than insured patients, and seek
emergency room care primarily
for convenience.34
Table 2 shows reimbursements
for uncompensated care and total
hospital expenditures in Oregon.
Although undocumented immi-
grants accounted for 4% of the
state’s population in 2010,35
emergency care reimbursements
for this population represented an
average of only 0.11% of overall
uncompensated care expenditures
in Oregon between 2006 and
2011. The same is true for hospi-
tal expenditures. Emergency care
reimbursements accounted for an
average of 0.01% of total hospital
expenditures statewide, similar to
estimates at the national level.25
DISCUSSION AND
IMPLICATIONS
An ongoing concern in immi-
gration and health discussions is
the extent to which limited access
to social and economic opportu-
nities creates structural barriers to
the social and economic integration
of immigrant families.10,25,36---38
As argued here, assumptions that
Latino immigrants are inherently
a burden to safety net services
should be challenged. By contrast,
it makes social and economic
sense to grant Latino immigrants
(both foreign- and US-born) ac-
cess to safety net services when
needed.
Health insurance coverage is
a case in point. Poor health in-
surance coverage rates among
noncitizens, regardless of their
immigration status, result from
cumulative disadvantages in
obtaining dependent employer-
based and public insurance.39
Public policies designed to provide
a health care safety net should
address the coverage needs of
low-wage noncitizens, including
López-Cevallos | Peer Reviewed | Commentaries | 783
subsidies for those who do not
qualify for coverage programs that
are not based on employment
status, to decrease health inequal-
ities in a group that, as the
evidence shows, contributes sig-
nificantly to state and federal
economies.40,41
Furthermore, excluding perma-
nent residents and undocumented
immigrants from accessing health
insurance leaves them dependent
on emergency rooms and dis-
courages early detection and
treatment of chronic conditions.42
Research shows that, in part
because Latinos are relatively
younger and healthier than the
general US population, they
tend to use fewer safety net
services.23,43,44 From a health
system perspective, it makes sense
then to include Latinos in health
insurance risk pools as a means of
containing rising health care
costs.22,37
In addition, policy changes that
offer a path to legal status for
undocumented immigrants may
facilitate their ability to obtain
better-paying jobs that offer health
care and other benefits. In the
context of health care reform, in-
surance coverage could have the
potential to increase their access to
preventive services and reduce
more expensive emergency and
hospital visits.44 This is certainly
not the case with the current
immigration reform bill passed by
the Senate, which provides a path
to permanent residency and
eventual citizenship for undocu-
mented immigrants but denies
them any access to safety net
services while they complete the
process of gaining citizenship
(which can require a decade or
more).45
As shown earlier, the majority
of the children of immigrants
across the nation are US citizens
with at least one noncitizen
 COMMENTARIES

institutions, including the meaning-

TABLE 2—Emergency Hospital Care Reimbursements to Undocumented Immigrants, Along With Total ful and active participation of La-
Uncompensated Care and Hospital Expenditures: Oregon, 2006–2011 tino immigrant leaders.62
Category 2006 2007 2008 2009 2010 2011 With its established reputation
as a social and health policy in-
Reimbursements, $a 549 794 1 162 307 1 587 359 1 217 570 1 083 738 851 765 novator,63 and with a Democratic
Uncompensated care expenditures (thousands), $b 754 449 877 482 984 362 1 203 297 1 223 696 869 450c majority in both its House of
Hospital expenditures (thousands), $d 7 034 000 7 500 000 7 887 000 8 441 000 9 057 193 9 718 368 Representatives and Senate, Ore-
Uncompensated care, % 0.07 0.13 0.16 0.10 0.09 0.10 gon is in a unique position to take
Hospital expenditures, % 0.01 0.02 0.02 0.01 0.01 0.01 leadership on this issue. However,
a
Data were derived from Novitas Solutions (see https://www.novitas-solutions.com/section1011/program/paymenthistory.html). such efforts should not be con-
b
Data were derived from Oregon Health Policy and Research, Research and Data Unit (see http://cms.oregon.gov/oha/OHPR/RSCH/Pages/ strued as partisan endeavors.
databank.aspx). More than four decades ago, in his
c
Data were available only through June 1, 2011.
d
Figures for 2006–2009 are Centers for Medicare & Medicaid Services (CMS) national health expenditures by state of residence; for 2010 and 1973 address to the Oregon leg-
2011, figures were based on the CMS average annual growth estimate for Oregon of 7.3% (see http://www.cms.gov/Research-Statistics-Data- islature, Republican governor
and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/Downloads/res-tables.pdf). Tom McCall said:

Quality of life is the sum total of

parent.8 The mixed legal status
of many Latino families has pro-
found implications for discussions
of safety net service policies. Given
the complex conditions of Latino
families, policymakers need to not
only take into account barriers but
also consider measures that explic-
itly seek to protect the health and
well-being of these families.46
There is much evidence attesting to
the relatively healthier status of
first-generation Latinos (even in
comparison with the “best-off”
group, non-Hispanic Whites) in
spite of their higher poverty, the
so-called “Latino paradox.”43,47,48
In addition to strong family sup-
port, research shows that first-
generation Latino families, particu-
larly those from rural areas, have
healthier food and exercise pat-
terns than mainstream US families
at similar levels of income and
education.43,49 However, research
also indicates that these family
strengths cannot thrive without
sustained community sup-
port.38,50,51
In nontraditional immigrant
states, policies to strengthen com-
munity and institutional support for
Latino families should be a priority
in the context of current health
care transformation efforts.52 Unlike
traditional immigrant states that
have more established Latino com-
munities (and therefore more robust
formal and informal support sys-
tems), nontraditional immigrant
states have much to do to nurture
their growing Latino immigrant
communities.
In the case of Oregon, a recent
positive step in this direction is the
statewide expansion of prenatal care
for undocumented patients initiated
in October 2013. No legislative
action was needed because pre-
natal care costs were included in
the Oregon Health Authority’s
existing budget.53 Other nontra-
ditional immigrant states could
certainly learn from this experi-
ence, enabled in part by the na-
tional health care reform context
and moved forward through
a coalition of governmental and
nongovernmental advocates. The
members of this coalition were
able to focus the debate around
public health and economic ben-
efits and stayed away from the
more “controversial” immigra-
tion issue.
By contrast, Senate bill 833,
intended to grant drivers’ cards
(which could be used only for driv-
ing and obtaining car insurance) to
Oregonians who are unable to
prove that they are in the United
States legally, was originally
scheduled to go into effect in Janu-
ary 2014 but has been referred to
the November 2014 ballot. Despite
the bill being framed as a public
safety and public health issue and
despite broad support from govern-
ment, business, community, and law
enforcement officials, opponents
were able to collect enough signa-
tures to delay its implementation for
at least another year.54
Nevertheless, safety net services
other than health care (e.g., ser-
vices provided by the Supple-
mental Nutrition Assistance Pro-
gram, TANF, and the Special
Supplemental Nutrition Program
for Women, Infants, and Children)
should also be reinforced.55---58 As
Table 1 shows, Latinos in Oregon
(and arguably in the nation as
a whole) constitute a young and
growing population with much
potential for contributing to our
society. At a time of budget deficits
and calls for reducing the size of
government, it is important to re-
member the important role of
strong community support sys-
tems for Latino immigrants and
other vulnerable populations.4,59---61
The experiences with prenatal
care and drivers’ cards in Oregon
show that health policy efforts
require building robust coalition
efforts across disciplines and
the fairness of our tax structure;
the caliber of our homes; the
cleanliness of our air and water;
and the provision of affirmative
assistance to those who cannot
assist themselves. True quality is
absent if we allow social suffering
to abide in an otherwise pristine
environment.64
In other words, public invest-
ments in community support sys-
tems (such as safety net services)
that assist Latino immigrants and
other vulnerable families will prob-
ably reap benefits for all. This is not
strictly a matter of social justice, but
one of sound public policy. j
About the Author
Daniel F. López-Cevallos is with the Center
for Latino/a Studies and Engagement,
Oregon State University, Corvallis.
Correspondence should be sent to Daniel F.
López-Cevallos, PhD, MPH, Center for
Latino/a Studies and Engagement, Oregon
State University, 262 Waldo Hall, Corvallis,
OR 97331 (e-mail: daniel.lopez-cevallos@
oregonstate.edu). Reprints can be ordered at
http://www.ajph.org by clicking the “Reprints”
link.
This article was accepted December 19,
2013.
Acknowledgments
This work was supported in part by the
Summer Institute on Mentoring Re-
searchers in Latino Health Disparities
at San Diego State University (grant
R25HL105430).
Thanks to Bob Bussel (Labor Educa-
tion and Research Center, University of
Oregon), Marcela Mendoza (Centro

784 | Commentaries | Peer Reviewed | López-Cevallos American Journal of Public Health | May 2014, Vol 104, No. 5

LatinoAmericano), Michaela Kiernan
(Stanford School of Medicine), and two
anonymous referees for reviewing pre-
vious versions of this article and providing
valuable feedback.
References
1. Hispanics of Mexican Origin in the
United States. College Park, MD: Pew
Hispanic Center; 2009.
2. Motel S, Patten E. Statistical Portrait of
Hispanics in the United States, 2011. College
Park, MD: Pew Hispanic Center; 2013.
3. Orozco RA. Racism and power:
Arizona politicians’ use of the discourse
of anti-Americanism against Mexican
American studies. Hisp J Behav Sci. 2012;
34(1):43---60.
4. Portes A, Fernández-Kelly P, Light D.
Life on the edge: immigrants confront the
American health system. Ethn Racial Stud.
2012;35(1):3---22.
5. Fix ME, Zimmermann W. All Under
One Roof: Mixed-Status Families in an Era
of Reform. Washington, DC: Urban In-
stitute; 1999.
6. Holcomb PA, Tumlin K, Koralek R,
Capps R, Zuberi A. The Application Pro-
cess for TANF, Food Stamps, Medicaid, and
SCHIP: Issues for Agencies and Applicants,
Including Immigrants and Limited English
Speakers. Washington, DC: Office of the
Assistant Secretary for Planning and
Evaluation, US Department of Health and
Human Services; 2003.
7. Chávez N, Telleen S, Kim YOR. Food
insufficiency in urban Latino families.
J Immigr Minor Health. 2007;9(3):197---204.
8. Capps R, Fix ME, Ost J, Reardon-
Anderson J, Passel JS. The Health and Well-
Being of Young Children of Immigrants.
Washington, DC: Urban Institute; 2005.
9. Taylor E. There has always
been. . .this hopefulness about the
country. Available at: http://articles.
chicagotribune.com/2006-10-29/
entertainment/0610280129_1_sermon-
hopefulness-black-church. Accessed
February 5, 2014.
10. Galarneau C. Still missing: undocu-
mented immigrants in health care reform.
J Health Care Poor Underserved. 2011;22
(2):422---428.
11. Hacker K, Chu J, Leung C, et al. The
impact of immigration and customs en-
forcement on immigrant health: perceptions
of immigrants in Everett, Massachusetts,
USA. Soc Sci Med. 2011;73(4):586---594.
12. Fujiwara LH. Immigrant rights are
human rights: the reframing of immigrant
entitlement and welfare. Soc Probl. 2005;
52(1):79---101.
13. Weiner M. Immigration: perspec-
tives from receiving countries. Third
World Q. 1990;12(1):140---165.
May 2014, Vol 104, No. 5 | American Journal of Public Health
COMMENTARIES
14. Portes A, Rumbaut RG. Immigrant
America: A Portrait. 3rd ed. Berkeley, CA:
University of California Press; 2006.
15. Van Hook J, Balistreri KS. Ineligible
parents, eligible children: food stamps
receipt, allotments, and food insecurity
among children of immigrants. Soc Sci
Res. 2006;35(1):228---251.
16. Fix ME, Passel JS. The Scope and
Impact of Welfare Reform’s Immigrant
Provisions. Washington, DC: Urban Insti-
tute; 2002.
17. Hagan J, Rodriguez N, Capps R,
Kabiri N. The effects of recent welfare and
immigration reforms on immigrants’ ac-
cess to health care. Int Migr Rev. 2003;
37(2):444---463.
18. Weathers A, Novak S, Sastry N,
Norton E. Parental nativity affects chil-
dren’s health and access to care. J Immigr
Minor Health. 2008;10(2):155---165.
19. Brown ER, Wyn R, Yu H,
Valenzuela A, Dong L. Access to health
insurance and health care for immigrant
children. In: Hernandez FJ, ed. Children of
Immigrants: Health, Adjustment, and Public
Assistance. Washington, DC: National
Academy Press; 1999:126---186.
20. Kaushal N, Kaestner R. Welfare
reform and health insurance of immi-
grants. Health Serv Res. 2005;40(3):
697---721.
21. Wallace SP, Leite P, Castañeda X,
Schenker M. Migration and Health: The
Children of Mexican Immigrants in the US.
Mexico City, Mexico: National Population
Council of Mexico and University of
California; 2009.
22. Goldman DP, Smith JP, Sood N.
Immigrants and the cost of medical care.
Health Aff (Millwood). 2006;25(6):
1700---1711.
23. Vargas Bustamante A, Fang H,
Garza J, et al. Variations in healthcare
access and utilization among Mexican
immigrants: the role of documentation
status. J Immigr Minor Health. 2012;
14(1):146---155.
24. López-Cevallos DF, Lee J, Donlan W.
Fear of deportation is not associated with
medical or dental care use among
Mexican-origin farmworkers served by
a federally-qualified health center faith-based
partnership: an exploratory study. J Immigr
Minor Health. 2013;Epub ahead of print.
25. Ku L. Health insurance coverage and
medical expenditures of immigrants and
native-born citizens in the United States. Am
J Public Health. 2009;99(7):1322-- 1328.
26. Mohanty SA, Woolhandler S,
Himmelstein DU, Pati S, Carrasquillo O,
Bor DH. Health care expenditures
of immigrants in the United States:
a nationally representative analysis.
Am J Public Health. 2005;95(8):
1431---1438.
27. McConnell KJ, Wallace N. Oregon’s
Cost-Shift: The Effect of Public Insurance
Coverage on Uncompensated Care.
Portland, OR: Oregon Office for Health
Policy and Research; 2007.
28. Cousineau MR, Farias AJ. Changes in
uncompensated pediatric ambulatory
care visits for uninsured children among
safety net providers after implementing
a health insurance program for children
of low-income families. J Public Health
Manag Pract. 2009;15(4):E1---E6.
29. Stimpson JP, Wilson FA, Eschbach
K. Trends in health care spending for
immigrants in the United States. Health
Aff (Millwood). 2010;29(3):544---550.
30. Hossain F, Tse A. Comparing the
House and the Senate health care pro-
posals. Available at: http://www.nytimes.
com/interactive/2009/11/19/us/
politics/1119-plan-comparison.html?
hp&_r=0. Accessed February 5, 2014.
31. Zallman L, Woolhandler S,
Himmelstein D, Bor D, McCormick D. Im-
migrants contributed an estimated $115.2
billion more to the Medicare trust fund than
they took out in 2002-- 09. Health Aff (Mill-
wood). 2013;32(6):1153-- 1160.
32. Uncompensated Hospital Care in
Oregon (1996 to 2006). Salem, OR: Of-
fice for Oregon Health Policy and Re-
search; 2007.
33. Castel L, Timbie J, Sendersky V,
Curtis L, Feather K, Schulman K. Toward
estimating the impact of changes in im-
migrants’ insurance eligibility on hospital
expenditures for uncompensated care.
BMC Health Serv Res. 2003;3(1):1.
34. Newton MF, Keirns CC, Cunningham R,
Hayward RA, Stanley R. Uninsured adults
presenting to US emergency departments:
assumptions vs data. JAMA. 2008;300(16):
1914---1924.
35. Passel JS, Cohn D. Unauthorized
Immigrant Population: National and State
Trends, 2010. Washington, DC: Pew
Hispanic Center; 2011.
36. Hernandez DJ. Children of Immi-
grants: Health, Adjustment, and Public
Assistance. Washington, DC: National
Academies Press; 1999.
37. Capps R, Rosenblum MR, Fix M.
Immigrants and Health Care Reform:
What’s Really at Stake? Washington, DC:
Migration Policy Institute; 2009.
38. Farquhar SA, Michael YL, Wiggins N.
Building on leadership and social capital to
create change in 2 urban communities. Am
J Public Health. 2005;95(4):596---601.
39. Derose KP, Escarce JJ, Lurie N.
Immigrants and health care: sources of
vulnerability. Health Aff (Millwood).
2007;26(5):1258---1268.
40. Ponce N, Cochran S, Mays V, Chia J,
Brown E. Health coverage of low-income
López-Cevallos | Peer Reviewed | Commentaries | 785
citizen and noncitizen wage earners:
sources and disparities. J Immigr Minor
Health. 2008;10(2):167---176.
41. Undocumented Workers Are Tax-
payers, Too. Silverton, OR: Oregon Center
for Public Policy; 2012.
42. DuBard CA, Massing MW. Trends
in emergency Medicaid expenditures
for recent and undocumented immi-
grants. JAMA. 2007;297(10):1085---
1092.
43. Franzini L, Ribble JC, Keddie AM.
Understanding the Hispanic paradox.
Ethn Dis. 2001;11(3):496---518.
44. Pérez-Escamilla R. Health care ac-
cess among Latinos: implications for so-
cial and health care reforms. J Hisp High
Educ. 2010;9(1):43---60.
45. González D. Immigration reform
bill’s path to citizenship draws criticism
from both sides. Available at: http://
www.azcentral.com/news/politics/
articles/20130418immigration-reform-
bill-citizenship-criticism.html. Accessed
February 5, 2014.
46. Angel R, Angel J. Who Will Care for
Us? Aging and Long-Term Care in Multi-
cultural America. New York, NY: New
York University Press; 1997.
47. Hummer RA, Powers DA, Pullum
SG, Gossman GL, Frisbie WP. Paradox
found (again): infant mortality among
the Mexican-origin population in the
United States. Demography. 2007;44(3):
441---457.
48. Markides KS, Coreil J. The health
of Hispanics in the southwestern
United States: an epidemiologic para-
dox. Public Health Rep. 1986;101
(3):253---265.
49. Riosmena F, Dennis JA. A tale of
three paradoxes: the weak socioeconomic
gradients in health among Hispanic im-
migrants and their relation to the Hispanic
health paradox and negative accultura-
tion. In: Angel JL, Torres-Gil F, Markides
K, eds. Aging, Health, and Longevity in the
Mexican-Origin Population. New York,
NY: Springer; 2012:95---110.
50. Denner J, Kirby D, Coyle K, Brindis
C. The protective role of social capital and
cultural norms in Latino communities:
a study of adolescent births. Hisp J Behav
Sci. 2001;23(1):3---21.
51. Hunter BD, Neiger B, West J. The
importance of addressing social determi-
nants of health at the local level: the case
for social capital. Health Soc Care Com-
munity. 2011;19(5):522---530.
52. Hacker K, Walker DK. Achieving
population health in accountable care
organizations. Am J Public Health.
2013;103(7):1163---1167.
53. McDonald J. Prenatal care expansion
a no brainer for undocumented patients.
 COMMENTARIES

Available at: http://www.thelundreport.

org/resource/prenatal_care_expansion_a_
no_brainer_for_undocumented_patients.
Accessed February 5, 2014.
54. Gaston C. Oregon driver card bill
headed to the November 2014 ballot.
Available at: http://www.oregonlive.
com/politics/index.ssf/2013/10/
oregon_driver_card_bill_headed.html.
Accessed February 5, 2014.
55. Black MM, Cutts DB, Frank DA, et al.
Special Supplemental Nutrition Program
for Women, Infants, and Children partic-
ipation and infants’ growth and health:
a multisite surveillance study. Pediatrics.
2004;114(1):169---176.
56. Cook JT, Frank DA, Berkowitz C,
et al. Welfare reform and the health of
young children: a sentinel survey in
6 US cities. Arch Pediatr Adolesc Med.
2002;156(7):678---684.
57. Cook JT, Frank DA, Berkowitz C, et al.
Food insecurity is associated with adverse
health outcomes among human infants and
toddlers. J Nutr. 2004;134(6):1432---1438.
58. Frank DA, Neault NB, Skalicky A,
et al. Heat or eat: the Low Income Home
Energy Assistance Program and nutri-
tional and health risks among children
less than 3 years of age. Pediatrics.
2006;118(5):e1293---e1302.
59. Ortega AN, Fang H, Perez VH, et al.
Health care access, use of services, and
experiences among undocumented Mexi-
cans and other Latinos. Arch Intern Med.
2007;167(21):2354---2360.
60. Pérez-Escamilla R, Garcia J, Song D.
Health care access among Hispanic im-
migrants: ¿alguien está escuchando? [is
anybody listening?] NAPA Bull. 2010;
34(1):47---67.
61. Portes A, Fernandez-Kelly P. No
margin for error: educational and occu-
pational achievement among disadvan-
taged children of immigrants. Ann Am
Acad Pol Soc Sci. 2008;620(1):12---36.
62. López-Cevallos D, Dierwechter T,
Volkmann K, Patton-López M. Strength-
ening rural Latinos’ civic engagement for
health: the Voceros de Salud Project. J
Health Care Poor Underserved. 2013;
24(4):1636---1647.
63. Jacobs L, Marmor T, Oberlander J.
The Oregon Health Plan and the political
paradox of rationing: what advocates and
critics have claimed and what Oregon did.
J Health Polit Policy Law. 1999;24(1):
161---180.
64. Oregon Historical Society. Tom McCall
quotes. Available at: http://www.ohs.org/
education/tom-mccall-better-oregon/quotes.
cfm. Accessed February 5, 2014.

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