Second-Class Care: How Immigration Law Transforms Clinical Practice in the Safety Net

Abstract

This article examines how U.S. immigration law extends into the health care safety net, enacting medical legal violence that diminishes noncitizens’ health chances and transforms clinical practices. Drawing on interviews with health care workers in three U.S. states from 2015 to 2020, I ask how federal citizenship-based exclusions within an already stratified health care system shape the clinical trajectories of noncitizens in safety-net institutions. Focusing specifically on cancer care, I find that increasingly anti-immigrant federal policies often reshape clinical practices toward noncitizens with a complex, life-threatening condition as they approach a “specialty care cliff” by (1) creating time penalties that keep many noncitizens in a protracted state of injury and (2) deterring noncitizens from seeking care through threats of immigration enforcement. Through these processes, medical legal violence also creates the potential for moral injury among health care workers, who must adapt clinical practices in response to socio-legal boundaries of belonging.