By Medha D. Makhlouf
A major contribution of health justice is that it provides a framework for understanding how universal access to health care protects collective, as well as individual, interests. The pandemic has underscored the collective nature of the health and wellbeing of every person living in the United States, regardless of immigration status.
In a 2019 article, Health Justice for Immigrants, I adopted and adapted the health justice framework to the problem of disparities in immigrant access to subsidized health coverage. I argued that, in future health care reforms, health justice requires that immigrants be included in the “universe” of universal access to health care. In this blog post, I revisit this argument in light of the COVID-19 pandemic.
This blog post applies the health justice lens to inequities in immigrant health and access to health care, drawing out lessons for the pandemic and post-pandemic eras. It describes three examples illustrating the utility of health justice for catalyzing cross-sector initiatives to improve health, reducing the role of bias in the design of interventions to address health disparities, and ensuring that such efforts are serving the needs of historically subordinated communities.
Cross-Sector Advocacy for Health Justice
Scholars of law, medicine, public health, anthropology, and sociology have recognized immigration law as a social determinant of health. Indeed, limited opportunities to regularize immigration status is the root cause of many of the barriers to health and health care that immigrants face. Eligibility for subsidized health insurance and other health-promoting public benefits depends on having U.S. citizenship or certain immigration statuses. The legal pathways to lawful status and citizenship determine one’s opportunities to work, which, in turn, can determine access to health insurance. Fear of immigration surveillance can dissuade immigrants and their family members from seeking health care or participating in health-promoting activities. For these reasons, researchers correctly predicted that immigrants’ health and wellbeing would be disproportionately affected by the COVID-19 pandemic.
Health justice “views access to health care as one among many social determinants of health deserving of public attention and resources.” Using a health justice lens to analyze the issue of immigrant access to health care highlights the importance of cross-sector collaborations in policymaking to improve health.
For example, a major goal of comprehensive immigration reform is to create a pathway to citizenship for undocumented immigrants, enabling more immigrants to qualify for health-promoting public benefits and better work opportunities, which are likelier to provide access to private health insurance. Obtaining a lawful status can also decrease fears of certain types of immigration surveillance. For these reasons, immigration reform should be considered a tool of health justice.
Reducing the Role of Bias
During the COVID-19 pandemic, some measures designed to enable compliance with public health guidance and reduce health disparities were affected by structural, social, and cultural biases that limit access for immigrants — particularly undocumented immigrants — despite immigrants’ heightened vulnerability to the effects of the pandemic. These measures include financial supports, such as enhanced federal subsistence programs, new poverty-prevention programs, and universal, no-cost access to the vaccine. They were designed to encourage and enable people with limited resources to change their behaviors to align with public health guidance — changes that are unprecedented and often socially disruptive, such as minimizing the number of close contacts, quarantining in cases of potential exposure to the virus, and caring for children when schools and childcare facilities are closed. The burden of complying with these measures falls hardest on the people with the fewest resources. However, several of these financial support programs either barred immigrants or uncritically adopted eligibility criteria that presumed that those who should benefit from assistance have U.S. citizenship or certain immigration statuses (or that their spouses do), Social Security Numbers, and certain forms of identification. Some measures presumed that recipients speak and read English, trust health care providers, and have no reason to fear government surveillance.
A health justice framework, with its commitment “to probing inquiry into the effects of racism, misogyny, classism, and other forms of structural, social, and cultural bias on the design and implementation of measures to reduce health disparities,” helps to uncover these oversights. Financial supports designed to enable compliance with public health guidance should seek to eliminate access barriers potentially affecting socially marginalized groups. Some concrete ways to do this in the context of immigration status-related barriers include eliminating eligibility criteria relating to citizenship or immigration status; accepting a broad range of documents to verify identity, including foreign passports or national identification cards; offering alternative ways to document income; enforcing language access laws and making public-facing materials available in numerous languages; investing in training for health care providers to provide culturally appropriate care; diversifying the health care workforce; and creating health care sanctuaries from immigration enforcement.
Engaging and Empowering Communities
Measures targeting health and health care disparities among immigrants, as with other populations, can be difficult to implement on a national level because of the diversity within the immigrant population, including diverse health needs, goals, and experiences, and political polarization relating to immigration issues. For example, during the pandemic, it has become clear that immigrants play a critical role in the essential workforce, in jobs that are among the lowest paid, such as farm work and food processing, to highly compensated positions in health care.
Health justice addresses this problem by encouraging “collective action grounded in community engagement and empowerment.” This third commitment of the health justice framework helps to ensure that interventions relating to immigrant health disparities do not regard the immigrant population as a monolith; rather, it encourages advocates to work alongside the members of the subpopulation of interest.
To ensure that interventions relating to immigrant health disparities are responsive to community needs and concerns, immigrant community members should be included in the conceptualization, planning, and implementation processes. Doing so reduces disparities in power between policy advocates and the historically marginalized populations they seek to study or impact, and helps to ensure that the interventions are tailored to the needs of historically subordinated communities. For all of these reasons, collective action at the local level — where immigrants often have more of a voice in the policy decisions affecting them — can be a suitable place to begin working for health justice for immigrants. For instance, during the recent resurgence of nativism at the federal level, there has been a notable growth of local “sanctuary immigration policies” responding to structural factors associated with immigrant status and poor health. Likewise, federal reforms aimed at particular subpopulations of immigrants, such as beneficiaries of Deferred Action for Childhood Arrivals (DACA) who provided health care and other essential services during the pandemic, may be more politically feasible than comprehensive reforms.
Health justice helps to illuminate why improving access to health care — although critical — is insufficient alone to address immigrant health disparities, especially during a public health emergency. Because immigration law is a social determinant of health, comprehensive immigration reform is a critical intervention. As stopgap measures, however, public health advocates and policymakers should ensure that existing interventions to reduce health disparities collaborate across sectors, eliminate biases that limit immigrants’ access to resources, and engage and empower immigrant communities.
Medha D. Makhlouf is an Assistant Professor and Director of the Medical-Legal Partnership Clinic at Penn State Dickinson Law. She has a joint appointment in the Department of Public Health Sciences at Penn State College of Medicine.