Cholesterol-lowering statins are a critical tool in the prevention of cardiovascular disease, including heart attacks and strokes. But access to these relatively cheap therapies is often influenced by various social factors, including race, ethnicity, and citizenship status.

“Noncitizens are often excluded from health insurance in the U.S., which can make it very difficult for them to get their medications,” said Jenny S. Guadamuz, PhD, a postdoctoral research fellow at the USC School of Pharmacy and the Schaeffer Center for Health Policy & Economics. “Furthermore, Latino and noncitizen neighborhoods endure poverty and inadequate access to healthcare providers and pharmacies—factors that may result in medications being less accessible.”

To better understand the impact of citizenship status, Guadamuz and colleagues evaluated levels of statin nonadherence in Latino neighborhoods within the three largest cities in the U.S. She finds neighborhoods with large noncitizen populations have much higher rates of statin nonadherence than Latino neighborhoods with fewer noncitizens.

Given the health inequities that already exist in these communities and the known effectiveness of these essential drugs, these results are troubling and should be something public health officials are aware of, Guadamuz explained.

The study was published in the Journal of the American Pharmacists Association.

In neighborhoods with higher rates of noncitizens, adherence decreased

Eighteen percent of adults in New York City, Los Angeles, and Chicago are immigrants without citizenship, according to recent data. Guadamuz and colleagues explored the relationship between the concentration of the noncitizen population and nonadherence to statins across neighborhoods in these cities with high populations of Latinos — including both citizens and noncitizens.

They find that individuals in neighborhoods with high concentrations of immigrants who are noncitizens have 10% to 40% higher rates of statin nonadherence. These disparities, however, were least pronounced in Los Angeles, where the county provides comprehensive healthcare coverage to noncitizens with and without documentation through My Health LA.

“Many non-citizens, especially undocumented immigrants, do not have access to jobs that provide private insurance and, in most states, are often ineligible for public insurance. Local programs, such as My Health LA, are usually the only source of healthcare and drug coverage,” explained Guadamuz.

Latino immigrants face significant barriers

Because Latino neighborhoods are often disenfranchised, with higher poverty rates, more uninsured adults, and fewer primary care providers and pharmacies, understanding and addressing barriers to care is vital.

“Efforts to improve the health of immigrant populations should consider less restrictive policies towards health coverage and other social protections,” said Dima M. Qato, PharmD, PhD, MPH, senior author on the study and senior fellow at the USC Schaeffer Center.

“These policies should ensure all residents, regardless of who they are and where they are from, are equally able to benefit from the resources and services available in the neighborhoods they live and work.” Qato holds the Hygeia Centennial Chair and is an Associate Professor at the USC School of Pharmacy and Director of the Program on Medicines and Public Health.

Latino immigrants who are noncitizens face additional challenges related to their status, partly from anti-immigrant rhetoric and policies. “The recent wave of anti-immigrant policies has resulted in reduced use of public insurance programs, even when immigrants are eligible. Many noncitizens even fear going to local health care facilities, including pharmacies,” Guadamuz said.

Policymakers should consider multipronged approach to increase medication access

The researchers argue that any efforts to improve prescription access and adherence should be multipronged, including employing strategies across different levels of government. In particular, Medicaid is an important program to consider expanding.

“California extended Medi-Cal to undocumented young adults and Illinois now provides health insurance to undocumented seniors, demonstrating that states can successfully use their funds to extend insurance coverage to those who are systemically excluded from federal programs,” Guadamuz explained.

“Alongside Medicaid, cities with large immigrant populations should also strengthen or develop new publicly funded programs that specifically target barriers in the availability, affordability and use of essential medications among noncitizens, including those that are undocumented,” Qato suggested.

“In all three cities, noncitizen neighborhoods had amongst the highest rates of nonadherence.  Given the cardiovascular benefits of statins, their underuse can contribute to disparities in mortality,” Qato said.

Policymakers and public health officials from other major cities with high concentrations of Latino noncitizen populations should consider these findings in their strategies to improve health outcomes for communities.

In addition to Guadamuz and Qato, study authors include Ramon A. Durazo-Arvizu, Martha L. Daviglus, Gregory S. Calip, and Edith A. Nutescu. Funding for this study was provided by the National Heart, Lung, and Blood Institute (T32-HL125294) and the Robert Wood Johnson Foundation Health Policy Research Scholar program.