This study sought to examine inequities in access to care by citizenship in the context of criminalization policies. Consistent with existing evidence that links citizenship stratification with access to health care , noncitizens in this study were less likely to report having a usual source of care than either naturalized or US born citizens. In the last 30 years, the federal government, states, and localities have increasingly enacted criminalization policies in the areas of policing, criminal justice, and identification and legal status verification . In this study, individuals lived in states with an average of over three criminalization policies, indicating that across the US many noncitizens seek health care in contexts of surveillance, policing, and enforcement. Examining the inequity in health care between noncitizens and US born citizens, we found that states with more criminalization policies had greater inequities in access. Each additional criminalization policy in individuals’ state of residence was associated with a lower likelihood that noncitizens had a usual source of care, compared to US born citizens. These findings indicate that citizenship inequities in health care access are not uniform; rather, states’ context of criminalization policy are related to the extent of health care inequity between citizens and noncitizens. Below we discuss the possible relationship between criminalization policy and health care and how this informs understanding of citizenship stratification and health care equity, as well as future research directions.
Our findings suggest that noncitizens in a more criminalizing state may face greater barriers to health care access that noncitizens in a less criminalizing state. A growing body of literature has linked restrictive, anti-immigrant policies to barriers in access to care . Qualitative studies of local enforcement policies found that immigrants of different noncitizen statuses, fearing deportation due to federal and local immigration enforcement policies, avoided seeking health care [30,31,32]. Residents felt that enforcement could have a negative impact on child health, their mobility (e.g. driving without a driver’s license), and their ability to access legal services; in particular, there was a perception that enforcement policies condoned racial profiling of Latinos. These studies were conducted in diverse immigrant communities, where individuals possessed different legal statuses, showing that the impact of enforcement policies extends beyond undocumented immigrants and affects all immigrants’ perceptions of safety and acceptance in their communities. The current study extends the existing evidence to show that it may not be any one single policy that creates barriers to care but the context of numerous policies that produce mechanisms of policing, enforcement, and surveillance. Overall contexts of criminalization policy likely produce a range of barriers related to the legal, economic, and social environment. It is worth noting that the policies included in the measure of criminalization did not include any formal health policies, furthering strengthening the evidence that non-health policies can have an impact on immigrant health care access.
These findings also suggest that criminalization policy is related to the creation of inequality between citizens and noncitizens across US states. Criminalization policy represents the intentional decisions of policy makers and efforts of policy advocates to be punitive towards noncitizens. These policies utilize state institutions (e.g., law enforcement, courts) to reinforce noncitizens subordinate status in a range of sectors and settings, from health care to the workplace to jails [33, 34]. Further, criminalization of immigrants occurs in the context of criminalization of people of color in US. Criminalizing immigrant policy co-occurs with the trend of using punitive policy mechanisms to criminalize people of color in the US, generally . In states and communities with criminalization policies, immigrant residents often report greater experiences of discrimination and policing practices that reinforce racial profiling [36, 37]. Considered from the perspective of citizenship stratification, state immigrant criminalization policies can be viewed as a marker of social inequality across the US population. In other words, states with more criminalization policies may be, on the whole, more inequitable across multiple sectors.
Our findings suggest that criminalization policies are related to the construction of citizenship stratification across geography and the related inequities in health care access by citizenship. These findings expand the research on citizenship stratification, providing empirical evidence of citizenship as a dynamic and changing social structure that inequitably positions immigrants within society. Criminalization policies constitute a broad context that, beyond the immediate impact on areas such as policing or enforcement, influences the nature of inequality among immigrants and native-born individuals. Changing, and increasingly criminalizing, policy contexts nationally and within states and localities are likely reinforcing the nation’s citizenship hierarchies.
Limitations and future directions
The US states offer an ideal comparative case for assessing the variation in citizenship stratification and health access related to criminalization policy. In the US, individuals reside under the same set of federal laws and policies, while being exposed to different state policy contexts. The US, however, has a unique history of migration and immigrant criminalization and integration. To understand the relationships between citizenship, criminalization policy, and health, future research should examine variation in citizenship stratification at different scales: within other nations and their states, across counties or municipalities that have distinct policies, or across federated regions, such as the European Union, which share some immigration policies, but determine immigrant policies at the national level.
Second, while this study provides a descriptive assessment of these complex dynamics between citizenship, policy, and health care access it is cross-sectional, limiting any causal interpretation or understanding of the stage at which policy may have the most significant impact on health care access (e.g., policy enactment, implementation, etc.). We controlled for political factors and did not find demographic factors to be significant in our model. The study design, however, is not intended to establish a causal link between citizenship, policy, and health care access, but to present current patterns of inequities across states that have enacted varying numbers of criminalization policies. Given existing evidence, it is likely that criminalization policies have an impact on barriers to care. It is also possible, however, that states in which there are existing barriers to care for noncitizens are more likely to enact criminalizing policies. These are related dynamics and therefore, do not diminish the significance of the study findings. Future research should disentangle these directions by assessing the relationships between the factors that influence policy-making and the health care access outcomes associated with policy enactment. For example, recent studies suggest that enactment of restrictive policies in states was associated with both state’s economic insecurity (e.g., unemployment rate) and demographic change (e.g., Hispanic population change) . Other studies found that that factors such as political polarization are also important . Research could examine the extent to which criminalization policy is a response to economic or demographic anxieties and how these state-level dynamics influence how policies unfold for the policing, surveillance, and enforcement that noncitizens may subsequently experience.
The presence of criminalizing policies and variations in health care inequities by citizenship status reflects an overall treatment of immigrants that determines their position in legal, institutional, and social realms in a state. Measurement of state immigrant policy, however, continues to be a challenge and our measure presents some limitations that can be addressed in future studies . Our measure of criminalization policy does not include an indication of the intensity of implementation, nor individuals’ experiences criminalization policy. While these approaches have been used in past studies, future studies could combine measures of the presence of policy, indicators of implementations (e.g., administrative records), and survey data on individuals’ experiences of policy. Future studies should similarly be based in a strong theoretical foundation.
Finally, citizenship status in the NHIS does not measure the legal and documentation statuses of noncitizen immigrants. If broken down by legal status groups, the most vulnerable among the noncitizen group, such as those who are undocumented or have Temporary Protected Status, may show an even greater inequality in access to health care compared to US born citizens. Future research should be conducted with data sets that include citizenship and legal statues.