Photo depicting a Latina-presenting doctor examining a Latino-presenting infant.

Weekend Reads | The ‘Hispanic Health Paradox’

by Kevin Schofield

This weekend’s read is a recent article by three Hispanic economics professors who have been attempting to unravel what’s known as the “Hispanic health paradox.” Here is their description of the paradox:

“Hispanics in the United States tend to have lower household income, education, and health insurance coverage when compared to non-Hispanic Whites. Despite these economic disadvantages, paradoxically, Hispanics have displayed an equality with or even advantages over other minority groups and non-Hispanic Whites across a wide range of health outcomes.”

To be more specific, they note that the average household income for U.S. Hispanic households is 26% less than non-Hispanic white households, yet the life expectancy for Hispanics is three years longer than for non-Hispanic whites. Hispanics also have nearly equal rates of infant mortality, and of mental illness.

Graph depicting the infant mortality rate among Hispanics with non-Hispanic Black groups having the highest infant mortality rate.
“Figure 2: Infant Mortality Rate; Sources: Ely and Driscoll (2021), Mathews and MacDorman (2013), and MacDorman and Mathews (2013). Note: Infant mortality rates are calculated as the number of infant deaths per 1,000 live births in the specified group. Data come from the NCHS linked birth/infant death datasets.” Fernandez, José, Mónica García-Pérez, and Sandra Orozco-Aleman. 2023. “Unraveling the Hispanic Health Paradox.” Journal of Economic Perspectives, 37 (1): 145-68. Copyright American Economic Association; reproduced with permission of the Journal of Economic Perspectives.

This discrepancy was first recognized in 1980, and four decades later has yet to be explained. There is another, related effect called the “healthy immigrant paradox”: The health of immigrants just after migrating is better than that of comparable native-born individuals — but worsens as they spend more time in their new country.

The researchers’ approach to understanding these paradoxes begins by removing the assumption that Hispanics should be approached as a single, monolithic demographic. Instead, they look separately at immigrants versus native-born Hispanics. They also disaggregate Hispanics by their country of origin. In addition, they look at the rates of specific disease rather than look at all health outcomes together. In all three cases they found some significant differences.

Graphs depicting the unadjusted and adjusted death rates of Hispanic groups over time with non-Hispanic whites having the highest death rates while non-Hispanic Blacks have the highest death rates when age adjustment is applied.
“Figure 1: Unadjusted and Adjusted Death Rates; Source: Xu et al. (2021). Notes: Death rates are deaths per 100,000 population. Mortality data is from the National Vital Statistics System (death certificates) and US Census population estimates. Estimates for males and females are shown in Figure A1 in the online Appendix.” Fernandez, José, Mónica García-Pérez, and Sandra Orozco-Aleman. 2023. “Unraveling the Hispanic Health Paradox.” Journal of Economic Perspectives, 37 (1): 145-68. Copyright American Economic Association; reproduced with permission of the Journal of Economic Perspectives.

Breaking out health outcomes by disease, they found that Hispanics have lower rates of cancer and heart disease, the two leading causes of death for all population groups. But they had higher rates than non-Hispanic white people for diabetes, kidney disease, and liver disease.

They further disaggregated the data by Hispanics’ country of origin and found even stronger differences: Cubans tended to have the best health outcomes, and Puerto Ricans have some of the worst. Similarly, immigrants had better health outcomes than U.S.-born Hispanics. There is one caveat to this though: The age demographics of each sub-group, when separated by country of origin, differed substantially; since we would expect older people to have more health issues, to get an apples-to-apples comparison, they needed to age-adjust the sample of each sub-group, and doing so erased some but not all of the per-country difference.

Bar chart depicting the difference in the likelihood of ever being diagnosed with condition relative to non-Hispanic white.
“Figure 3: Difference in the Likelihood of Ever Being Diagnosed with Condition Relative to Non-Hispanic White; Source: Authors’ calculations using 2006–2019 NHIS-IPUMS data.” Fernandez, José, Mónica García-Pérez, and Sandra Orozco-Aleman. 2023. “Unraveling the Hispanic Health Paradox.” Journal of Economic Perspectives, 37 (1): 145-68. Copyright American Economic Association; reproduced with permission of the Journal of Economic Perspectives.

The statistics for obesity, an underlying cause of several other health problems, are a good example: Overall Hispanics have a lower incidence of obesity than non-Hispanic whites, but in age-adjusted population groups the statistics are similar (though the paradox still exists given the overall lower economic status of Hispanics in the United States). Obesity rates are highest in the Mexican and Puerto Rican communities, though the researchers note that it appears to be an increasing problem in all Hispanic communities. Obesity is lower among immigrants, but the data shows that it increases for individuals as they spend more time in the United States. 

Still, none of this explains why the paradox exists. The researchers argue that there is no single cause; instead they propose three different contributing factors. The first factor is that there is “sampling bias” in the health statistics — and in the population itself. To start, they note that there is evidence that healthier individuals tend to be the ones who immigrate, since they are the ones who can pay the physical costs of immigrating; though the data shows that subsequent generations of their offspring tend to “revert to the norm.” The researchers also cite the “salmon bias” hypothesis: that many immigrants tend to return to their country of origin to live out their final years, with “a compulsion to die in one’s birthplace.” And those individuals would not be recorded in U.S. mortality statistics. Politics complicate our understanding of a potential “salmon bias”: The cost of returning to Cuba from the United States is high, but on the other hand, undocumented immigrants have a more difficult time accessing health care here and may have even more motivation to return home when their health begins to deteriorate.

There may also be measurement errors adding bias to the numbers, given that much of the health data is self-reported by individuals. Undocumented immigrants often have strong reasons to opt out of data-gathering efforts. The researchers also suggest that over subsequent generations there can be “ethnic attrition” as individuals stop self-identifying as Hispanic or from a specific country of origin.

A second factor that the researchers suggest may contribute to the paradox is cultural and lifestyle differences, in particular smoking, alcohol consumption, and diet. Research shows that immigrants are less likely to smoke and drink. Hispanics in general are less likely to drink than non-Hispanic whites, with Cubans having the lowest likelihood and Puerto Ricans the highest among Hispanics. 

A third factor they discuss is health insurance and health care usage. In part this could be a reporting bias: Those with health insurance may be more aware of — and subsequently report — their own health conditions than those who aren’t insured. On the other hand, lack of health care may affect individuals’ health outcomes. As of 2020, about 93% of non-Hispanic whites in the United States have some form of health insurance, compared to about 83% for Hispanics (which is a great improvement over the 69% rate in 2008, thanks largely to the Affordable Care Act). Not surprisingly, the rate is much lower for non-citizens. Also, 56% of Hispanics have no regular place where they receive health care, which suggests that many may be missing out on regular preventative health care: checkups, vaccinations, and treatment for small issues before they become big ones. 

The researchers present several takeaways from their dive into the “Hispanic health paradox.” First, they reiterate that they don’t believe there is a single cause for it but instead multiple factors that contribute. Second, a lack of availability for health care may specifically explain some of the disparities for specific diseases such as hypertension, diabetes, and liver disease — and may also lower disease awareness. Third, both the “Hispanic health paradox” and the “healthy immigrant” paradox seem to diminish in successive generations. And finally, that it’s not helpful to treat Hispanics as one monolithic population for the purposes of this kind of analysis because doing so obscures many important differences within the population.

Unraveling the Hispanic Health Paradox

Kevin Schofield is a freelance writer and publishes Seattle Paper Trail. Previously he worked for Microsoft, published Seattle City Council Insight, co-hosted the “Seattle News, Views and Brews” podcast, and raised two daughters as a single dad. He serves on the Board of Directors of Woodland Park Zoo, where he also volunteers.

📸 Featured Image: Photo via Gods_Kings/, edited by the Emerald team.

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