How does satisfaction with medical care differ by citizenship and nativity status? A county-level multilevel analysis

Purpose of the Study: 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. Design and 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). Implications: 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.