American uncovered : structures and patterns of immigrant health uninsurance

In this thesis I investigate disparities in U.S. immigrants’ access to health insurance, a strong proxy for differential access to quality care in the American non-universalized health system. The United States is notorious among industrialized nations for its high proportion of uninsured residents—about 15% of the total population. U.S. immigrants, however, lack health insurance at a rate nearly double or triple the national average. The immigrant uninsurance problem has been exacerbated by large-scale, deliberate economic and political adjustments to American health insurance institutions, and immigrants’ structural relations to these institutions. The two institutions I scrutinize in this thesis are (1) the employer-sponsored insurance system for immigrant workers, and (2) government-sponsored insurance systems for lower-income immigrants in need. Using a combination of primary and secondary data analysis, expert interviews, and a synthesis of multidisciplinary research, I map out the recent history and driving logic(s) of the immigrant uninsurance phenomenon, both for the United States in the 1980s-1990s and for the “case study” of Minnesota in the 2000s. During the 1980s and 1990s, new immigrants to the United States in need of health coverage were “squeezed” by both of the largest health insurance institutions. First, immigrants were negatively affected by a polarized private labor market that increasingly limited its provision of health insurance benefits to those workers at the higher end(s) of the skill/income spectrum. Second, immigrants were actively targeted by a federal government that decided to explicitly exclude many of them from the protection of the national health insurance safety net. The end result of these negative “stresses” was that by the 2000s, immigrants’ chances of obtaining health insurance were at once increasingly “personalized” (i.e. dependent upon immigrants’ individual and community characteristics), and increasingly dependent upon localized economic, political, and institutional contexts. In Minnesota, for example, the immigrant uninsurance rate in the 2000s remained lower than the national average. This outcome was enabled, however, by specific demographic and institutional contexts unavailable in most other states. The health insurance system for immigrants in the 2000s, in other words, became increasingly geographically fragmented and contingent.Arts, Faculty ofGeography, Department ofGraduat