Figure S1.1. Undocumented Worker. The Taxpayer March on DC proceeds down Pennsylvania Avenue toward the Capitol on Saturday, September 12, 2009. (CQ Roll Call via AP Images)

 

 

SECTION I

Inclusions and Exclusions

When the Affordable Care Act (ACA) was enacted, it represented a sweeping transformation of the U.S. health care system designed to make access to health insurance more equitable and affordable. However, it built upon a legacy of existing stratification that had long excluded people by class, occupation, race, ethnicity, gender, and sexuality. This foundation was coupled with a series of political and legal compromises and concessions, including the U.S. Supreme Court ruling that permitted states to decide whether or not to expand Medicaid (in those that didn’t, the “coverage gap” was created). As a result, while many people found themselves newly included, others experienced no change to their health insurance status or were purposely shut out. While the law represented an extension of social protections to some groups, it also created new forms of exclusion as access to affordable coverage options were highly segmented by state of residence, income, and citizenship status.

Figure S1.2. Texas Insurance Sign-Up. Eric Sosa, center, and Nancy Maldonado, right, listen to a volunteer counselor with Insure Central Texas explain health insurance options, Tuesday, October 1, 2013, in Austin, Texas. Texas hospitals, clinics, and charities are gearing up to help uninsured Texans enroll in health care exchanges after Governor Rick Perry declared the state government would do as little as possible to help implement the Affordable Care Act. (AP photo/Eric Gay)

Many immigrants were explicitly excluded from the ACA, including undocumented persons and those with less than five years of residency in the United States. The ACA is layered on an existing patchwork of policies that already created segregated effects, especially the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA). However, as the following chapters show, immigrant groups in the United States are not monolithic but instead are stratified by many chaotic bureaucratic categories. Because the ACA maintained most of these prior exclusions—such as the exclusion of “nonqualified” immigrants from Medicaid—while simultaneously creating new exclusions (such as that of DACA recipients, who arrived as children and were granted a temporary reprieve under President Obama), this lead to quite a checkered landscape of eligibility for immigrants in mixed-status families (Castañeda). Moreover, as the federal government has devolved to states the decision about whether to restore inclusion in Medicaid for certain unqualified immigrants (such as legal permanent residents, who have been in the United States for less than five years) (Joseph)—as well as what services Emergency Medicaid should provide undocumented immigrants (Melo), this landscape of exclusion varies dramatically across states. In addition, some states that had inclusive practices before the ACA and that included these immigrants (e.g., Massachusetts) continued to do so, while others later used the state option to expand eligibility to these groups (e.g., California). Finally, the chapter by Andaya shows that some groups experienced exclusions and inequality not because they were left out of the ACA, but because of the kind of coverage they were afforded.