Citizenship status and cost-related nonadherence in the United States, 2017–2021



To assess inequities in prescription medication use and subsequent cost-related nonadherence (CRN) and cost-saving strategies by citizenship status in the United States.

Data Sources/Study Setting

National Health Interview Survey (2017–2021).

Study Design

This cross-sectional study examined noncitizen (n = 8596), naturalized citizen (n = 12,800), and US-born citizen (n = 120,195) adults. We also examined older adults (≥65 years) separately, including noncitizens without Medicare (a group of importance given their immigration-related barriers to health care access). Multiple mediation analysis was used to examine differences in CRN and determine whether economic, health care, and immigration factors explain observed inequities.

Principal Findings

Noncitizens (41.9%) were less likely to use prescription medications than naturalized (60.5%) and US-born citizens (68.2%). Among prescription medication users, noncitizens (13.8%) were more likely to report CRN than naturalized (9.5%) and US-born citizens (11.0%). CRN differences between noncitizens and naturalized citizens (OR 1.38, 95% CI 1.21–1.44) and between noncitizens and US-born citizens (OR 1.23, 95% CI 1.07–1.35) were explained by insurance status and food insecurity. Only 4.9% of medication users turned to alternative therapies to lower their drug costs, but there were no substantial differences across citizenship status. More medication users requested lower-cost prescriptions (19.0%); however, noncitizens were less likely to make these requests. Older noncitizens without Medicare, of whom 23.9% requested lower-cost drugs, were an exception. Noncitizens (5.8%), particularly older noncitizens without Medicare (21.8%), were more likely to import their drugs than naturalized (3.5%) and US-born citizens (1.2%).


Noncitizens experience a high burden of cost-related barriers to prescription medications. Efforts to reduce these inequities should focus on dismantling health care and food access barriers, regardless of citizenship status.

The full study can be viewed at Health Services Research.

Guadamuz, J. S., & Qato, D. M. Citizenship status and cost‐related nonadherence in the United States, 2017–2021. Health Services Research.

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