Decomposing Healthcare Access Inequities: The Role of Discrimination and Intersectionality Among Refugee Newcomers In the United States

Background and Purpose:
Refugee newcomers in the United States experience persistent barriers to healthcare access that extend beyond individual or material constraints and reflect broader structural and institutional inequities. Discrimination is increasingly recognized as a key determinant of these barriers, yet it is often framed as an individual-level experience rather than a structurally embedded process that shapes access to care. Existing research also rarely examines how discrimination operates across intersecting social positions. This study examines how perceived discrimination is associated with healthcare access barriers and how these relationships are patterned by race and sex. It further quantifies the extent to which disparities in access barriers reflect differences in observable characteristics versus underlying structural processes.

Methods:
Data were drawn from the 2020-2022 Annual Survey of Refugees (N=4,246), a nationally representative sample of resettled refugees. Healthcare access barriers were measured as a continuous index (0-5) capturing the cumulative number of reported obstacles to care. Negative binomial regression models estimated associations between perceived discrimination and healthcare barriers, adjusting for demographic, socioeconomic, linguistic, and health-related covariates. To assess mechanisms, decomposition analysis was used to partition the mean difference in barriers between those reporting any discrimination and those reporting none into explained and unexplained components. Mediation analysis examined whether perceived discrimination functioned as an intermediate pathway linking biological sex to healthcare barriers. Intersectional variation was assessed using a three-way interaction model (Discrimination × Race × Sex). Robust standard errors and bootstrapped confidence intervals were applied.

Results:
Perceived discrimination was the strongest predictor of healthcare access barriers. Refugees reporting discrimination experienced a 47% higher expected count of barriers (IRR=1.47, 95% CI [1.34, 1.62], p<.001). The mean difference in barriers between groups was 0.56 (SE=0.10, p<.001). Of this disparity, 42.3% (Δ=0.24) was explained by observed characteristics, while 57.7% (Δ=0.32) remained unexplained. The explained portion was primarily associated with physical health, English proficiency, financial hardship, and employment, reflecting differences in resources and health status. The remaining unexplained component suggests the influence of institutional and structural processes not captured by measured covariates. Mediation analysis indicated a significant indirect effect of sex through discrimination (B=0.061, 95% CI [0.030, 0.094]), accounting for approximately 35% of the total association. Intersectional analyses revealed significant heterogeneity (F(18,3585)=2.31, p<.01), with Black, Middle Eastern/North African, and Asian women experiencing the highest predicted barriers under high discrimination, while White men reported the lowest.

Conclusions and Implications:
Healthcare access disparities among refugee newcomers are not fully accounted for by individual-level differences and are substantially shaped by structural and institutional inequities. Discrimination operates not only as an individual experience but as a mechanism through which intersecting systems of inequality are reproduced in access to care. The large unexplained component of disparities points to institutional processes, including systemic exclusion and differential recognition within healthcare systems. Addressing these inequities requires moving beyond individual-level interventions toward structurally informed and intersectional approaches that target the conditions under which access is constrained.