Immigrant Exclusion and Inclusion: The Importance of Citizenship for Insurance Coverage before and after the Affordable Care Act

Abstract

Abstract While the Affordable Care Act (ACA) promised to reduce inequalities in insurance coverage between Latinos and non-Latinos by expanding coverage, it also excluded a large portion of noncitizen immigrants. Past research has demonstrated that among Latinos, further inequalities have developed between citizens and noncitizens after the ACA took effect, but it is unclear if this pattern is unique to Latinos or is evident among non-Latinos as well. I use data from the 2011 to 2016 waves of the National Health Interview Survey (NHIS) (n = 369,386) to test how the relationship between citizenship status (native citizen, naturalized citizen, or noncitizen) and insurance coverage changed after the ACA, adjusting for health, demographic, and socioeconomic factors. I disaggregate the analysis by ethnicity to test whether this change differs between Latinos and non-Latinos. The analysis finds that after the ACA, naturalized citizens across ethnic groups moved toward parity with native citizens in health insurance coverage while the benefits of the ACA for noncitizens were conditional on ethnicity. For non-Latinos, lacking citizenship became less disadvantageous for predicting insurance coverage while for Latinos, lacking citizenship became even more disadvantageous in predicting insurance coverage. This bifurcation among noncitizens by ethnicity implies that while the ACA has strengthened institutional boundaries between citizens and noncitizens, this distinction is primarily affecting Latinos. The conclusion offers considerations on how legal systems of stratification influence population health processes.