Discrimination and intersecting inequities to healthcare access among refugee newcomers in the United States.

BACKGROUND: Refugee newcomers in the United States experience pronounced disparities in healthcare access, shaped not only by individual-level or material constraints but also by systemic and structural inequities. Perceived discrimination, particularly when compounded by intersecting identities such as race and sex, may significantly influence these access barriers. This study investigates the relationship between perceived discrimination and healthcare access barriers among resettled refugees, examining whether this relationship is statistically associated with biological sex and moderated by race and sex. METHODS: Data were drawn from the nationally representative Annual Survey of Refugees (2020-2022), comprising 4,246 respondents. Healthcare access barriers were operationalized as a continuous index of self-reported obstacles to care. Negative binomial regression was used to estimate the association between perceived discrimination and healthcare barriers, adjusting for demographic, socioeconomic, and health-related covariates. Blinder-Oaxaca decomposition quantified the explained and unexplained components of disparity in barriers by discrimination status. A mediation model assessed whether perceived discrimination functioned as an intermediate variable linking sex to healthcare barriers, and a three-way interaction model (Discrimination × Race × Sex) evaluated intersectional moderation effects. RESULTS: Perceived discrimination emerged as the strongest independent predictor of healthcare barriers, even after adjusting for English proficiency, financial hardship, and physical health. Refugees reporting discrimination faced significantly higher barriers (mean difference = 0.56, p < .001). Notably, 57.7% of the disparity in access remained unexplained by observable covariates, reflecting potential structural and institutional inequities. Mediation analysis indicated an indirect association between sex and healthcare barriers through perceived discrimination (indirect effect B = 0.061, 95% CI [0.030, 0.094]), representing about 35% of the total association (B = 0.176, p < .001). Discrimination's effects varied significantly across racial and sex groups (F(18, 3585) = 2.31, p < .01), with Black, Middle Eastern/North African, and Asian women reporting the highest access barriers under high discrimination, while White men reported the lowest. CONCLUSIONS: These findings underscore the structurally embedded nature of refugee healthcare inequities. Discrimination functions as both a pathway and amplifier of access disparities, particularly for multiply marginalized groups. Addressing these inequities requires intersectional, structurally competent strategies that treat discrimination as a modifiable determinant of health and prioritize institutional accountability in refugee health policy and practice.