Inclusions and Exclusions: Stratification by Immigration Status

When ACA was enacted, it was built upon an already extant system of inequality in the United States:

• gender
• race
• social class
• immigration status
• occupation
• ethnicity

this coupled with a series of legal compromises and political concessions, most importantly, the decision of the supreme court to allow states to decode whether to expand medicare (or not - leaving access gaps), left some excluded from coverage and others with no improvement to their existing insufficient plans.

Many immigrants were excluded from coverage (ACA maintained many of the immigrant exclusions that came before it) 

• undocumented
• those with less than 5 years residency
• Personal Responsibility and Work Reconciliation Act (PRWORA)
• maintained old exclusions from Medicaid coverage and created new ones for certain classes of immigrants (like DACA)
• Many mixed status families found themselves with a "patchwork" of coverage.
• Varies dramatically across states
• Some states kept their inclusive policies and some used states rights to add them, but most did not. 
• Some failed to be included because of the kind of coverage they were offered.

2010, ACA extended healthcare to more than 20 MILLION individuals in the US who previously lacked insurance. Immigrants are stratified by bureaucratic categories that are created by the state and determine INCLUSION or EXCLUSION.

• these inclusions and exclusions are often contradictory
• 11.2 undocumented immigrants are excluded
• created a clearer distinction between undocumented immigrants and the morally "deserving" population
• boundary expansion for US citizens and long-term legal immigrants and boundary contraction for undocumented immigrants.
• This chapter deals with legal US immigrant citizens who found themselves in contradictory situations when attempting to access healthcare.
1. US citizens children in mixed staus families
2. The exclusion of young adults -DACA (deferred action for childhood arrival)
3. a loophole that allowed some immigrants to qualify for insurance subsidies, while US citizens in the same state did not.
• Reactions of States: 
• Some states expanded Medicaid, created health-care exchanges, and supported the application process.
• Ex: Texas was totally noncompliant. (undocumented and working poor almost 12 million were left out of coverage eligibility). 
• Left local ngos and hospital emergency rooms with the burden of care.
• highest uninsured rate in the country, and the tex/mex border has the highest uninsured rate in the worst state.
• The policy convergence between immigration reform and healthcare reform in ACA - reinforced categories of "deservedness" and citizenship.

Immigration Status and Healthcare Reform

• "Lawfully Present" immigrants under ACA
• lawful permanent residents
• refugees
• asylees
• Cuban and Haitian entrants
• certain victims of domestic violence and trafficking survivors and their families
• persons granted withholding of deportation/removal
• temporary protected status
• lawful temporary residents
• those with "deferred status" (except DACA)
• applicants for deferred status

NOT ALL LAWFULLY PRESENT PERSONS WERE QUALIFIED

One must be both "qualified" (PRWORA) and "lawfully present".

• Lawfully present immigrants who were in the US less than 5 years were NOT QUALIFIED for Medicaid unless the individual state in which they resided had EXPANDED their medicaid. 

• "Not Lawfully Present" Individuals
• Undocumented immigrants
• only qualified for emergency room care, prenatal care under Medicaid, and Federally Qualified Health Centers (FQHC)- and some state and local programs where they existed.
• FQHC
• Struggle for solvency
• staff shortages
• inadequate networks of specialists 
• poor health outcomes
• Only exist in 1/3 of the areas designated "medically underserved"
• provide only limited preventative and primary services

LIMITING ACCESS TO HEALTHCARE IS A WAY TO LIMIT IMMIGRATION IN THE US

• healthcare is seen as a scarce limited good with no acknowledgment that it is a right, and that it is explicitly withheld from those we believe are undeserving.

3 CASE STUDIES: Mixed Status Families

1. people will often not access care for their children (or take subsidies and tax credits) because they fear being on a "list" or "owing the government something" which may compromise their attempts at legal status. (even though this should not legally happen)
• mixed status families are more and more common-confusing healthcare eligibility and immigration eligibility
• people will often move in and out of households as needs for care demand 
• 2.3 million mixed status families have about 45 million children who are US citizens by birth
• works to destabilized already stressed family units and worsen healthcare outcomes
• some parents will not enroll eligible children if other children are not eligible. 
2. This resulted in increased health disparities within families and for familes as a whole with undocumented (und uncovered under ACA) family members. 
3. Public support for the undocumented has also lessened
4. OPT not to enroll eligible children because of fear of repercussions later, but also because they would need to report their household income placing them further in the spotlight without legal status. (fear of deportation)
5. DREAM ACT vs DACA
• unlike the proposed Dream Act, DACA was simply a stop gap against deportation rather than a path to legal status or citizenship.
• DACA produced patterns of disenfranchisement for over 800,000 young people
• DACA could get insurance from their employers because they could work, but rarely utilized it because they are young and healthy and unused to accessing primary care or using insurance, or paying deductibles
• They have all the responsibilities of citizenship (taxes, etc.) without any of the benefits.
6. Immigrants receive benefits where citizens do not
• states that did not expand Medicaid created a disparity between citizens and legal immigrants resident less than 5 years who were eligible for subsidies if they earned less than the poverty level. (they were prohibited from Medicaid before ACA). 

ANTI-IMMIGRANT POLICIES DO NOT JUST EFFECT IMMIGRANTS - THEY AFFECT EVERYONE (e.g., if undocumented workers who pay taxes like everyone else were to be covered, they would lower our over all healthcare costs. Most are healthy and low "risk")

CASE 1:

Anti-immigrant legislation has far reaching affects beyond the undocumented. The designation of "illegality" negatively affect mixed-status families and extended to those who were legally present, even those that are citizens.

CASE 2:

Government rollback of benefits left DACA recipients without healthcare even though others with deferred action qualified. 

CASE 3:

The rejection of medicaid expansion by some states inadvertently created a disparity between low income citizen and legal immigrants.

The ACA intensionally increased and intensified immigrant's exclusion from the healthcare system. 

• symbolic boundaries have been more institutionalized into national health legislation and practice.
• resulted in escalated symbolic and social exclusion, especially the undocumented
• Prior to 2010, many more shared the lack of access to healthcare

Shows how tying immigration policy to healthcare reform or using healthcare reform as a tool of immigration reform is faulty. It has only resulted in the increase stigmatization of the undocumented, and the loss of coverage for many poor immigrants and citizens in states where medicaid was not expanded.