Perceived general, mental, and physical health of Latinos in the United States following adoption of immigrant-inclusive state-level driver’s license policies: a time-series analysis

In 2019, it was estimated that over 60 million Latino individuals lived in the United States (U.S.), roughly 19% of the total U.S. population [1]. Twelve states had a population of one million or more Latino residents in 2019; California, Texas, Florida, New York and Arizona were the top five states, with four of these bordering Mexico [2]. Almost 22% (13 million) of Latino persons in the country are not U.S. citizens [3], however estimating the number of undocumented (do not possess a valid visa or other immigrant documentation) immigrants is difficult. The Department of Homeland Security estimates that roughly 13% (under 9 million) of Latinos in the U.S. are undocumented [4].

In the U.S., state-level immigration policies increasingly affect the lives of Latino immigrants [5, 6]. State-level policies can either increase or constrain immigrants’ access to services and benefits. Additionally, state immigration policies shape the immigrant experience of settlement and incorporation and reflect the state’s position towards immigrants [6, 7]. One example of immigrant-inclusive policies are state laws that allow for the issuing of driver’s licenses regardless of legal immigration status, henceforth referred to as immigrant-inclusive policies. As of December 2021, 16 U.S. states and the District of Columbia have such policies [8, 9].

Allowing immigrants, regardless of citizenship or legal documentation status, to obtain driver’s licenses has the potential to impact the general, physical, and mental health of Latinos (Fig. 1). For undocumented immigrants, possessing a driver’s license can improve access to healthcare and social services, and social, recreational and employment opportunities [7], and conversely, requiring a form of identification limits their ability to access public services [10]. Additionally, fears of deportation and detention that would be magnified when driving without a license, and associated elevated chronic stress could negatively impact general, physical, and mental health [11].

Anti-immigrant policies in the U.S. affect the health and well-being of both U.S.-born and immigrant Latinos, and documented and undocumented noncitizens, due to spillover effects and because citizenship status cannot be visually ascertained[11]. Because half of all undocumented Latinos live in mixed-status families (e.g., parents may be undocumented while children have legal status in the U.S.) [12], some of the health benefits associated with undocumented immigrants’ ability to obtain a driver’s license could extend to Latinos who are U.S. born, naturalized, and/or legal residents. Furthermore, anti-immigrant policies that reflect or engender anti-immigrant attitudes and racial profiling have been shown to generate equal levels of psychological distress among U.S.-born and immigrant Latinos [13]. Finally, legal enforcement of driver’s license policies, e.g., traffic stops by police, affect all Latinos, including legal residents and U.S. citizens. One study employing complex standardization and analyses of over 100 million traffic stops found that police require less suspicion during traffic stops to search Black and Hispanic drivers than White drivers, suggesting persistent racial bias [14]. In fact, racial profiling is considered a public health and health disparities issue in the U.S. because it can indirectly and directly cause adverse health consequences through stress, trauma and anxiety [15].

Despite the potential economic and health benefits of having access to a driver’s license, the impact of enacting immigrant-inclusive license policies on Latino health in the U.S. is currently unknown. Thus, the aim of the current study was to measure the impact of enacting immigrant-inclusive license policies on the physical, mental, and general health of all Latinos (undocumented, legal residents, and U.S. citizens) living in the U.S. We hypothesized that these policy changes would be associated with better physical, mental, and general health among Latinos in the U.S. Because significant expansion of health insurance access occurred in some U.S. states at the same time as the enactment of immigrant-inclusive driver’s license policies (2013–2015), we only included states in this study where this health insurance expansion occurred. A major part of the Affordable Care Act (ACA), signed into law by President Obama in 2010 and implemented in 2014, was to expand eligibility criteria for Medicaid, a federal and state joint program that provides health insurance coverage for low-income citizens and documented immigrants (undocumented were not eligible), which disproportionately included Black and Latino individuals [16]. However, states were allowed to opt out of Medicaid expansion. Thus, we only included states that were similar in terms of Medicaid expansion but differed on adoption of immigrant-inclusive policies.

Overall, there were 123,807 Latino participants included in the analysis (intervention states: n = 66,805; control states: n = 57,002). A breakdown of participant demographics is reported in Table 1, stratified by status (intervention vs. control state) and time period (pre-, during, and post-implementation). Overall, demographics remained relatively consistent across time among participants living in both the intervention and control states. Participants from intervention states were slightly less likely to have a higher education, taken the BRFSS survey in English, and had a routine physical exam checkup in the past year.

In this national analysis of Latino adults, we found that those living in states where immigrant-inclusive license policies were enacted between 2013–2015 (as well as Medicaid expansion) saw an improvement in perceived physical and mental health, whereas states that did not enact such license policies (but did enact Medicaid expansion) did not see similar improvements during the same time period. Specifically, enacting an immigrant-inclusive license policy was associated with an average of 0.64 fewer poor physical health days per month among Latino adults overall, and a 11% reduction in the proportion of Latino adults having poor physical health days each month. And while the average number of perceived poor mental health days did not change after implementation of immigrant inclusive license policies, a 17% reduction in the proportion of Latino adults experiencing poor mental health days was observed. License expansion did not appear to impact perceived general health.

State-level immigrant policies such as limiting access to driver’s licenses (and state identification cards) affect health and well-being at the institutional and individual levels [7]. Lack of personal identification has been identified as a barrier to accessing social services for marginalized populations [20]. Exclusionary immigrant policies, such as the 2010 Arizona Senate Bill 1070 immigration law, have resulted in decreases in the use of preventative healthcare services and public assistance [21]. Access to a driver’s license affects physical and social mobility, employment, mental health, and access to healthcare services and social institutions (schools and social programs) for undocumented Latinos, legal residents, and U.S. citizens [7]. Social program eligibility criteria and policies can also influence social assistance participation. For instance, application forms for many social services require a form of identification [10]. Undocumented immigrants may not have U.S. identification documentation or may fear using their home country identification; thus, the ability to obtain a driver’s license can provide the needed reassurance to drive an automobile and utilize public services.

Possession of a driver’s license is associated with increased vehicle ownership and employment rates by facilitating job accessibility among undocumented immigrants [22]. The ability to expand maximum commuting distance allows for a greater chance of finding employment, working longer hours, and earning higher wages, thus increasing financial stability which positively impacts health [23].

Despite Medicaid expansion, we did not see any change in perceived mental or physical health among Latinos living in states that did not have immigrant-inclusive license policies. This may be explained partly by the “chilling effect” that discourages undocumented immigrants from using public services and being in public places [6, 10]. This “chilling effect” is exacerbated by policies like Secure Communities that require state and local law enforcement to partner with federal immigration authorities [10]. Such policies can increase fear and stress and can have negative health impacts [6]. Potentially detrimental health effects of not having a license, or vice-versa, the salutary effects of having a license, could extend to Latino U.S. citizens and legal residents living with mixed-status families or communities [12]. The stress and fear associated with family members’ legal status has been shown to provoke depression and anxiety among Latino U.S. citizens and has been associated with more cardiovascular risk factors [24, 25]. As has been pointed out previously, racial profiling, e.g., racial discrimination during traffic stops including searches prompted by the driver’s race, is a public health and health equity issue and impacts all Latinos, irrespective of their legal status [14, 15]. Thus, anti-immigrant policies harm the health of immigrant groups living in the U.S. and Latino communities and exacerbate racial health disparities among citizens and non-citizens alike [11].

This study has several strengths and limitations. First, we conducted a national analysis using a quasi-experimental design and a negative control group, which allows us to estimate the effect of immigrant-inclusive license policies on Latino health. While we restricted our intervention and control groups to states which expanded Medicaid in 2014, it is still possible that other policies or external influences, e.g., other health or immigration surveillance policies or programs that differentially affected the implementation and control states could be causing the observed effect. Additionally, these results may not generalize to states that have not expanded Medicaid under the Affordable Care Act. Moreover, because immigration status is not captured in BRFSS, we were unable to differentiate the effects of these policies among undocumented, legal resident, and U.S. citizen Latinos living in the U.S. We were also only able to investigate perceived poor mental and physical health days, which are based on individual perceptions using single-item measures and not validated scales or diagnoses. Finally, although the BRFSS is a nationally representative longitudinal survey that can assess trends and changes over time, individual participants are not followed longitudinally; therefore, we are unable to assess individual-level changes.

In this multi-state analysis assessing the impact of immigrant-inclusive license policies (i.e., state laws that allow for the issuing of driver’s licenses regardless of immigration status), we found that enacting immigrant-inclusive license policies (2013–2015) decreased the number of perceived poor physical health days per month, the proportion of adults experiencing poor physical health, and the proportion of adults experiencing poor mental health among Latinos. This decrease was not observed among states that did not have inclusive policies, even though they had expanded Medicaid through the Affordable Care Act in 2014. Immigrant-inclusive driver’s license policies deserve further assessment regarding their potential to reduce health disparities via increasing access to employment opportunities, healthcare and social services that might enhance health, and decreasing racial profiling, fears of deportation, and stress that can harm health. Because anti-immigrant policies can harm Latino communities regardless of immigration status and further widen health inequities, implementing state policies that do not restrict access to driver licenses based on immigrant status documentation could help address upstream drivers of such inequities.