Undocumented and

Uninsured:
Exploring the Dynamics of Federalism in the Shadow of
Healthcare Expansion
ALEX REYES
POSC 644
Undocumented Immigrants and
the Affordable Care Act
Literature
Social Construction
◦ Ingram, Helen, Schneider, Anne L., Deleon, Peter., Social Construction and Policy Design – Excerpt
Theories of the Policy Process – Ed. Paul A. Sabatier.

Federalism
◦ Schnuck, Peter H. “Taking Immigration Federalism Seriously”, University of Chicago, Legal Forum
◦ Elias, Stella Burch. ”The New Immigration Federalism” The University of Iowa, College of Law

State/Local Measures of Ensuring Accessibility

◦ Marrow, Helen B., Joseph D., “Excluded and Frozen Out : Unauthorized Immigrants (Non) Access
to Care After US Health Care Reform. Journal of Ethnics and Migration Studies
◦ Marrow, Helen B. “Deserving to a Point: Unauthorized Immigrants in San Francisco’s Universal
Access Health Care Model.
◦ Portes, Alexander., Fernandez-Kelly, Patricia., Light, Donald., “Life on the Edge: Immigrants
Confront the American Health System.” Ethnic and Racial Studies,
 ◦ This paper will aim to understand the following:
◦ How the social construction of the undocumented
immigrant as inherently deviant and undeserving and how
this results in policy that seeks to codify this classification
at the federal level
◦ This leads to an noting of the social construction of the
concept of citizenship.
Premise ◦ The ramifications of federal policies of exclusion and how
the onus of responsibility for ensuring public welfare shifts
onto states and localities with a key focus on the dynamics
of federalism and the concept of “immigration federalism”
through an analysis
◦ State/local efforts to ensure basic accessibility to health care
through the use of literature the looks into sanctuary city dynamics
which is the off spring for health based efforts of integration
◦ State/local efforts to address the ramifications of illegal border
flows as the state and localities face the primary burden of dealing
with immigration.
Policy Timeline – Immigration
Policies/Court Rulings Post 1980s
June 15, 1982 – Plyler v Doe 457 U.S 202 Ruling
November 6, 1986 – Immigration Reform and
Control Act (IRCA) is signed by President Regan
November 8, 1994 – CA Proposition 187 is passed
by CA Voters
August 22, 1996 - Personal Responsibility Act and
Work Opportunity Reconciliation Act (PRWORA)
September 30, 1996 – Illegal Immigration Reform
and Immigration Responsibility Act
June 2, 1998 - Proposition 227 (Elimination of
Bilingual Education in CA)
March 23, 2010 – Affordable Care Act Exacted
April 23, 2010 – SB 1070 is enacted in Arizona
June 15, 2012 – Deferred Policy for Childhood
Arrivals (DACA) Issued
April 16, 2013 – Introduction of S.744 The Border
Security, Economic Opportunity and Immigration
Modernization Act of 2013
September 5, 2017 – DACA Rescinded by Trump
Administration
November 21, 2017 - Judge William Orrick of CA
issues permanent block of Trump Administration
Executive Order 13768 regarding Sanctuary Cities
and Federal Grants.
(1982)
Plyler v Doe 457 U.S 202 - 1982 Supreme Court ruling in which the court ruled that undocumented immigrants are within the jurisdiction of
the states in which they reside and are therefore under the equal protection clause of the 14th Amendment

(1994)
Proposition 187 is passed by CA Voters which establishes a state run citizenship screening that prohibited undocumented immigrants from
accessing various public services.

(1996)
Personal Responsibility Act and Work Opportunity Reconciliation Act (PRWORA) and the IIRIRA are enacted which bar undocumented
immigrants from receiving welfare benefits, social security and asks for proof of citizenship in order to access federal public benefits.

(2005)
Real ID Act of 2005 – Establishes statutory guidelines of removal cases and includes further border security measures, requires states to
verify an applicant’s legal status before issuing a drivers license or personal identification card that may be accepted for federal purposes.

(2010)
Affordable Care Act is enacted. Legislation is the most significant overhaul of the US healthcare system since 1965 and aims at increasing
accessibility yet excludes roughly 11.2 million undocumented immigrants from accessing the legislations provisions.

(2017)
November 21, 2017 - Judge William Orrick of CA issues permanent block of Trump Administration Executive Order 13768 regarding Sanctuary
Cities and Federal Grants.
San Francisco redefines “citizenship” and
ensures limited accessibility.
In terms of immigration the city has a progressive stance going back to the
1980s with the enactment of a ”sanctuary” declaration making the city a
refuge for Salvadorian and Guatemalan refugees.

This has gradually morphed in a codified active ordinance that prohibits the
collection of legal status unless directed by state/federal statue of court
decision and prohibiting the cooperation of public service providers with
federal immigration authorities.
This was followed up with the implementation of a municipal ID ordinance
which went into effect in 2009 which offered a form of identification to all
city residents regardless of legal status with the idea of integrating the city’s
approximately 40,000 undocumented immigrants which in the process
bestows undocumented immigrants a de-facto form of legitimacy as part of
the local community.
 San Francisco redefines “citizenship” and ensures limited
accessibility.
In 2007, undocumented immigrants were granted limited accessibility to primary care and treatment with the
adding of “Healthy San Francisco” in the city’s well stablished public benefits system.
o This provided universal access to designated hospitals and FQHC’s (Federally Qualified Health Centers) for
all local resident adults ages 18-65 with incomes under 500% of the federal poverty level who were
ineligible for other forms of public coverage.
o Income and residency rather than documentation and legal status were the basis for eligibility and
inclusion.
o For those ineligible, service fees opened up access to these benefits.
While the ACA excludes undocumented immigrants from its provisions, this group benefits unwittingly with the
increase in funding to FQHC’s.
o The purposely inclusive policy categorizes undocumented immigrants and individuals within the local based
framework of “we” and shifts away from the conception of the other and the foreigner which dominate the
federal framework. Furthermore it shifts away from the deviancy frame which dominates the national
discussion through the portrayal of immigrants and morally deserving members of the community who
should be eligible for care.
Source: Creating Conditions to Support Healthy People: State Policies that Affect the Health of Undocumented Immigrants and their Families – Study by the University of
California Global Health Initiative – Authors – Michael A. Rodriguez, Maria Elena Young and Steven P. Wallace
Conclusion
This topic provides an interesting conversation
of federalism amidst the backdrop of stalled
efforts at reforming the American immigration
system

That being said there is uncertainty in the study

of this topic as immigrants are constrained by
the lack of full recognition as citizens therefore
despite being subject to the principle of due
rights, health care is not a fundamental right in
the US.