Immigration and Immigrant Policies, Health, and Health Equity in the United States

Abstract

Policy Points.

• There is growing attention to the role of immigration and immigrant policies in shaping the health and well‐being of immigrants of color.

• The early 21st century in the United States has seen several important achievements in inclusionary policies, practices, and ideologies toward immigrants, largely at subnational levels (e.g., states, counties, cities/towns). National policies or practices that are inclusionary toward immigrants are often at the discretion of the political parties in power.

• Early in the 21st century, the United States has implemented several exclusionary immigration and immigrant policies, contributing to record deportations and detentions and worsening inequities in the social drivers of health.

More than 281 million people worldwide live outside their country of birth, and 15% of the United States population (50.6 million people) are immigrants. ¹ As migration rises across the globe, attention to the health of migrants and immigrants is a vital aspect of public health in the United States and worldwide. Immigrants’ rights and access to opportunities and health‐promoting resources are directly linked with their health and health care access. ² , ³ , ⁴ , ⁵ , ⁶ , ⁷ , ⁸ , ⁹ Policies and social mobilization surrounding immigrant health are particularly important to examine, since immigration and health are two politically contentious social issues that frequently converge. ³ , ⁴ , ¹⁰ Further, the well‐being of immigrant communities has implications for entire societies, making immigration an increasingly important topic of discussion, debate, policy, practice, and research. ¹⁰ , ¹¹

In this Perspective, using the United States as a case study, we review existing literature regarding societal ideologies, policy, research, and practice toward immigration and immigrants, with a focus on gains and successes to promote immigrant health, continuing problems that have implications for immigrant health, potential solutions, and implications for public health over the coming decades. We situate research and action on immigration and health in a global context, then describe key concepts central to immigrant health. We then focus on structural factors that shape the health and well‐being of immigrant communities in destination countries, namely immigration and immigrant policies. As public health professionals, we ground this review in a human rights perspective that values the health and well‐being of all people regardless of nationality, mode of migration, or legal status. We also ground our discussion in structural racism and health equity lenses, as these provide rigorous perspectives for assessing how policies and other structural factors influence immigrant health. We close by suggesting structural interventions that are necessary to address the societal and political factors that contribute to immigrants’ poor health in the United States and globally.

Contemporary Global Im/migration Patterns

Recent and ongoing migration patterns indicate that a growing segment of the global population is on the move. ¹² , ¹³ Between 2000 and 2020, the global immigrant population grew from 173 million—2.8% of the total global population—to 281 million—3.6% of the total global population. ¹⁴ Numerous factors influence international migration, including colonialism, globalization, war, conflict, violence, human rights violations, economic crises and poverty, technological transformations, climate change, family unification, and, most recently, the COVID‐19 pandemic. Climate change has contributed to a growth in climate migration, which spurs individuals, families, and communities to leave their homes when a major climate disaster strikes and/or climate stressors such as droughts, flooding, and sea‐level rise create conditions in which it is not possible to remain in their community. ¹⁵ , ¹⁶ Climate change has disproportionately affected small island nations and territories, areas with vulnerable geographies (e.g., deforestation, drought), and fragile ecologies. ¹⁵ , ¹⁶ With growing climate extremes, climate change catalyzed migration for 22.5 million to 24 million immigrants in 2017 alone. ¹⁷ The World Bank estimates that extreme weather events will generate 143 million climate migrants in Latin America, sub‐Saharan Africa, and Southeast Asia by 2050. ¹⁸

As of 2020, nearly one‐quarter of the global migrant population resided in the United States ¹⁴ and more than 44% of the US immigrant population emigrated from Asia, including the Middle East, or Latin America. ¹⁹ Estimates suggest 45% of immigrants residing in the United States are naturalized citizens, 27% have lawful permanent residence, 5% have temporary lawful residence, and 23% have undocumented legal statuses. ¹⁹

Key Concepts

To ground the field in the literature regarding immigration and health, we offer definitions that conceptualize immigration and health within the context of the structural forces that shape human migration, immigrant integration, and social, political, and economic responses to immigrants—all of which are processes that can influence health. We lay a foundation to advance critical scholarship and action that promotes the health and well‐being of all people, including immigrant communities. (Related topics central to immigration and migration, such as migration journeys, permanence and porousness of immigration experiences and immigrant identities, and the hardening of national borders, are beyond the scope of this manuscript.)

Racism, Racialization, and Immigration

Immigration and immigrant policies have long been racialized and racializing. ²⁰ , ²¹ , ²² Ideologies rooted in white supremacy have fomented cultural narratives that, in turn, influence the parameters of proposed and enacted immigration policies. Box 1 expounds on the interconnectedness of racialized cultural narratives and immigration policies. While there is growing attention to the role of structural racism in shaping the health and well‐being of racially minoritized immigrant populations, ²³ , ²⁴ , ²⁵ , ²⁶ limited public health scholarship has situated immigrant health in the United States within a structural racism framework. ¹¹ Racism is rooted in ideological understandings and assertions of race as fixed and acontextual, rather than socially constructed and varying over time and place. ²⁰ , ²⁴ , ²⁵ , ²⁷ , ²⁸ , ²⁹ Racism produces and reinforces racial hierarchies that operate to limit the rights and opportunities of populations who have been classified as a minority racial group through a set of interconnected systems and prejudicial treatment at multiple levels. ²⁴ , ²⁵ , ²⁷ , ²⁸ , ²⁹ , ³⁰ , ³¹ Structural racism encompasses the interconnected ideological, social, economic, and political systems that stratify how individuals are treated and their access to opportunities and resources based on one's location within socially constructed racial/ethnic hierarchies. ²⁷ , ²⁸ , ³²

Immigration policies are not proposed and/or enacted in a vacuum. Instead, they reflect cultural narratives prevailing at the time. Ideologies rooted in racism give life and shape to narratives that typically dehumanize and vilify immigrant groups from nonwhite and/or non‐European countries.

In response to these narratives, policies are written to uphold racist ideologies by further excluding and criminalizing immigrants. For example, the presence and arrival of Latin American immigrants to the United States has fomented racist cultural narratives about this group of immigrants. ¹ In turn, governmental agencies at the federal, state, and local levels have proposed and/or enacted immigration and immigrant policies that have heightened border security along the US‐Mexico border; excluded immigrants from accessing services (e.g., charging out‐of‐state tuition for undocumented immigrant students); and codified racial profiling through laws such as Arizona's S.B. 1070 (“Show me your papers”), which grants law enforcement the ability to inquire about someone's legal status if they are suspected of being undocumented.

Likewise, immigration and immigrant policies can shape narratives and ideologies. For example, policies that exclude immigrants from accessing social and health care services can reinforce ideologies that question immigrants’ entitlement to and eligibility for such services and resources, even as new services (such as COVID‐19 testing and vaccination) become available. Similarly, immigration enforcement policies, such as those that have contributed to the detention of immigrant children and separation of immigrant children from caregivers detained at the southern US border, have contributed to discourse and policy advocacy to lessen the harshness of immigration enforcement policies, particularly for immigrant children.

Box 1. Racialized Cultural Narratives and Immigration Policies

Racism at different levels affects access to opportunities and is rooted in histories of and ongoing colonial practices and legacies. ²⁷ , ²⁸ , ²⁹ , ³⁰ , ³¹ As an example of how race and nativity intersect and how immigration policies are racialized, in the United States—where anti‐Black racism has a stronghold—Black people are more likely than any other racial group in the United States to have police encounters, a central mechanism for catalyzing interactions with immigration enforcement agencies and deportation. ³³ , ³⁴ , ³⁵ Though Black immigrants represented 7.2% of the US noncitizen population in 2013, they represented 10.6% of immigrants in deportation proceedings during the 2003–2015 period. ³³

Immigration and Immigrant Policies

Immigration policies refer to policies that affect the opportunity and pathways to migrate, which in turn shape who can migrate and legal status in the destination country. ³⁶ In the United States, immigration policies are under the purview of the federal government, including through legislative action (which has more enduring policy impacts), and presidential discretion through executive action (which changes according to the priorities of each administration). Immigration policies include, for example, prioritizing acceptance of or restricting migration to the United States based on country of origin, as well as apprehension and deportation of immigrants with an unauthorized or other vulnerable legal status. Table 1 presents examples of exclusionary and inclusionary immigration policies, which illustrate the role of federal policies and action in shaping migration opportunities, legal status, immigrant incorporation, detention, and deportation.

Table 1.

Examples of Exclusionary and Inclusionary Immigration and Immigrant Policies at Federal, State, and Local Levels, United States, 2022

Policy Domains	Exclusionary Policies and Practices		Inclusionary Policies and Practices
Immigration Policies	Policy Level	Policy Description	Policy Level	Policy Description
Migration and Legal Status	Federal Policy	Historical racially targeted admissions policies, including the Chinese Exclusion Acts and the Johnson Reed Act of 1924 (created national origins quotas)	Federal policy	Temporary statuses for specific groups, including Temporary Protected Status (TPS) and Deferred Action for Childhood Arrivals (DACA)
Immigrant Policing/Surveillance	Federal Policy	Illegal Immigration and Immigrant Responsibility Act of 1996 (added penalties for undocumented immigrants who were charged with committing crimes in the United States)	None	The federal government has taken no recent action to limit immigration enforcement actions such as immigrant policing and surveillance
Detention	Federal Policy	Mandatory detention for immigrants with certain felony charges	None	Detention is a human rights violation.
Deportation	Federal Policy	Expansion of felony categories that deem an immigrant deportable	None	Deportation is a human rights violation.
Economic Stability	Federal Policy	Earned Income Tax Credit (provides tax credits for low‐income working families with children) excludes undocumented immigrant workers from eligibility	State Policy	State‐level child income tax credits for all families (provides tax credits for low‐income working families with children)
	State Policy	State‐funded unemployment insurance programs that exclude undocumented workers	State Policy	State‐level COVID‐19 pandemic financial relief funds available to undocumented immigrants
	Federal Policy	COVID‐19 pandemic relief programs that exclude undocumented immigrants from participating
Education Access and Quality	State Policy	Charging out‐of‐state tuition for undocumented students who are in‐state residents	State/Local Policy	School district safe haven policies that protect students regardless of legal statuses and implement supportive practices to include and protect immigrant students and their families
			State Policy	In‐state public university tuition and financial aid for undocumented students
Policing and Law Enforcement	Federal Policy	Collaboration between local law enforcement agencies (e.g., county sheriff's office, local police) with immigration authorities; Intergovernmental Service Agreements (IGSAs) for local jails to detain immigrants (contracts between Immigration and Customs Enforcement and local jails)	State Policy	State and local‐level prohibitions of law enforcement collaboration with immigration authorities
	State Policy		Local Policy
	Local Policy		State Policy	Expanded eligibility for driver's licenses for undocumented immigrants
Social and Community Context	State Policy	English‐only laws	State Policy	State and municipal language access regulations
			Local Policy
	Local Policy		State Policy	Dropping the use of the xenphobic term “alien” in state code
			Local Policy	Local laws permitting noncitizens to vote in local elections
Housing	Federal Policy	Section 8 housing programs that exclude non‐qualified immigrants	Federal Policy	Fair housing laws protecting immigrants against discrimination due to legal status
			State Policy
			Local Policy
Health Care Access and Quality	Federal Policy	Medicaid and Affordable Care Act insurance programs that make undocumented immigrants ineligible for health insurance through federally funded Medicaid or public insurance exchanges	State Policy	Local‐level health insurance coverage programs for all residents
	Federal Policy	Medicaid eligibility requirement that immigrants with green cards must wait 5 years to be eligible for federally‐funded Medicaid	Local Policy
Labor and Employment	State Policy	State mandates of employers to use E‐Verify (an on‐line system that allows employers to verify workers' eligibility to work in the United States)	State Policy	State prohibitions of using E‐Verify (an online system that allows employers to verify workers' eligibility to work in the United States)

Immigrant policies regulate the lives of immigrants and immigrant communities in the country in which they live. ³⁶ In the 21st century, immigrant policies are increasingly incorporated into a number of policies, such as health care, law enforcement, education, employment, and social programs. Immigrant policies can operate at federal, state, and local levels. For example, the Affordable Care Act is among the most recent federal exclusionary immigrant policies as it systematically excludes recent immigrants and immigrants with an unauthorized legal status from Medicaid expansions. ³⁷ Some states, cities, towns, or counties have implemented inclusionary or exclusionary immigrant policies through, for example, allowing immigrants with an undocumented legal status to access state‐issued government identification cards or health insurance coverage. ² , ⁷ , ³⁸ The exclusionary and inclusionary policies shown in Table 1 highlight opportunities for and interplay between federal, state, and local policies to shape opportunities and resources for immigrant communities.

Citizenship and Legal Status

The concept of “illegality” refers to ongoing processes by which social structures such as immigration and immigrant laws and policies, practices, ideologies, and discourse criminalize and create categories of marginalization for immigrants and immigrant communities. ³⁹ , ⁴⁰ Citizenship and legal status refer to the socially, politically, and juridically produced status of individuals within a nation, including the multiple legal statuses of noncitizen immigrants who have varying risk for deportation. Legal status is not necessarily linear and may vary over the life course. ⁴¹ Individuals and families may be actively engaged in a process of changing their legal status, ⁴² and people may slip from a more protected legal status such as visa holder or a temporary protected status to an undocumented legal status. Further, the benefits conferred by moving along a continuum of legal statuses may not be continuous across legal statuses. ⁴³ Citizenship encompasses multiple dimensions, including rights, political enfranchisement, and identity. ⁴⁴ See, for example, Chavez for a review of conceptualizations of citizenship. ⁴⁵ In the context of nation‐states, citizenship refers to a legally recognized form of membership in a given nation. ⁴⁶ De Genova points out that while the concept of “citizenship” within the context of nation‐states may seem inclusionary at first glance, it is intrinsically exclusionary, as the concept of citizenship creates categories of citizens and noncitizens. ⁴⁶

As illustrated in Figure 1, there are a range of legal statuses in the United States. Legal statuses represented at the bottom of the pyramid are generally characterized by greater social, economic, and political disenfranchisement. For example, undocumented immigrants hold an unauthorized legal status. Other particularly vulnerable legal statuses include temporary protected status (e.g., available to individuals from designated countries) and Deferred Action for Childhood Arrivals (DACA), which is available to young adults who migrated without authorization to the United States as children. Additional temporary legal statuses include visa holders (e.g., student, tourist, occupational), persons seeking asylum, persons seeking refugee status, and those who have experienced a form of violence recognized by the law. Temporary statuses, however, leave immigrants with uncertainty regarding renewal and access to resources. ⁴⁰ , ⁴² Lawful permanent residence (LPR) status grants immigrants the right to live and work in the United States on a presumably permanent basis; however, people with legal permanent residency can face deportation if sentenced for certain crimal offenses. In the United States, even among citizens there are tiers in who is constructed as worthy of citizenship and the full rights of citizenship. For example, the life experiences and societal treatment of US‐born citizens and naturalized citizens may differ. ⁴⁷ , ⁴⁸ Further, birthright citizenship has been questioned for children of undocumented immigrants and Puerto Ricans. ²⁰ , ⁴⁵ These examples highlight the concept of racialized legal status and are an important reminder that in the United States, citizenship has been created to grant and protect the rights of those classified as “white.” ⁴⁵ , ⁴⁹ (See, for example, the Naturalization Act of 1790.)

Figure 1.

Legal and Social Construction of Legal Statuses, United States, 2022.

Abbreviations: DACA, Deferred Action for Childhood Arrivals; TPS, temporary protected status.

Illegality and legal statuses are also experienced by families and communities. Mixed‐status families comprise members with a range of legal and citizenship statuses, including unauthorized legal statuses, naturalized or US citizenship, and/or temporary statuses. ⁵⁰ Mixed‐status communities refer to geographic and identity‐based communities where members hold a range of legal and/or citizenship statuses. ⁶

Past Gains, Successes, Failures, and Continuing Problems to Promote Immigrant Inclusion and Health

Societal attitudes toward immigrants and the policies that determine immigrants’ rights influence immigrants’ integration into new societies and, ultimately, their health. ¹⁰ , ⁵¹ There is mounting evidence that xenophobic attitudes and restrictive immigration and immigrant policies are associated with worse health outcomes among both immigrants and some US‐born populations. ² , ⁸ , ⁵² , ⁵³ , ⁵⁴ Because the health and health care access of immigrants has direct implications for all members of a society, we discuss the past gains and successes toward social, economic, and political inclusion of immigrants—critical processes to protect their health; we also identify the failures and continuing problems that may have long‐term repercussions for immigrant health. We focus on two key societal areas—societal values, beliefs, and practices and immigration and immigrant policies—and then discuss how public health research has evolved to examine and address these.

Societal Values, Beliefs, and Practices

Successes in Immigrant Inclusion and Health. Despite the proliferation of exclusionary and restrictive immigration and immigrant policies, the early 21st century in the United States has brought some gains and successes in immigrant inclusion, such as a growing immigrant rights movement, implementation of inclusionary state and local policies, and executive orders to mitigate the impact of restrictive federal policies.

Recent trends point to increasingly favorable public attitudes toward immigrants in the United States. ⁵⁵ The Trump administration's approach to immigration garnered national attention and revealed common practices such as separating minors from their caregivers and holding children in cagelike cells. Public outrage at the detention of families during the Obama and Trump administrations and the separation of families at the US‐Mexico border suggest a coalescing of societal values opposed to the detention of children and recognizing that separation of families is harmful to well‐being and constitute human rights issues. ⁵⁶ Further, the criteria for national belonging expanded such that birthplace and religion were viewed as less important in 2020 than in 2016. ⁵⁵

The early 21st century has also been a significant moment for social mobilization around immigration. For example, immigrant activists, many of them undocumented youth, engaged in marches and demonstrations that were critical to securing the DACA program. ⁵⁷ , ⁵⁸ Immigrant rights organizations have also spearheaded efforts to bring attention to the inhumane immigration enforcement apparatus. Under the Obama administration, as news became public regarding the detention of immigrant families in response to high levels of migration at the southern US border, individuals organized to find ways to support immigrants in detention. ⁵⁹ , ⁶⁰ , ⁶¹ These examples of immigrant organizing and power building are important gains in immigrant rights matters in the United States, which may not only advance support for inclusionary policies but also strengthen community networks and social support systems that are associated with better health outcomes. ⁶²

Failures and Continuing Problems. Despite gains in a growing immigrant rights social movement, there are indications that white supremacy is increasingly overt in the treatment of immigrants of color and their families and communities. The early 21st century has seen rising anti‐immigrant sentiments and xenophobic discourse in high‐income countries worldwide, including in the United States. ⁶³ , ⁶⁴ , ⁶⁵ At the heart of anti‐immigrant sentiments that uphold exclusionary immigration and immigrant policies is an underlying acceptance of immigrant criminalization, which casts some immigrants as “deserving” and others as “undeserving.” ⁶⁶ , ⁶⁷ This ideology overlooks the criminalization of people of color overall, justifies exclusionary immigration policies that link local policing with immigration enforcement, and disadvantages Black and Latino immigrants and other immigrants of color. ⁶⁸ Additionally, this ideology diverts attention away from immigration as a human rights issue and the need for inclusive policies, ⁶⁹ , ⁷⁰ , ⁷¹ instead situating the topic as highly divisive and political. While overall national patterns indicate a general consistency or slight decline in the US population's concerns about immigration, ⁷² there has also been a trend toward increasingly extremist anti‐immigrant ideologies and organized anti‐immigrant movements. ⁷³ , ⁷⁴ In the United States, there were increased reports of anti‐immigrant sentiment following the election of Donald Trump, whose campaign rhetoric employed racist and xenophobic tropes. ⁶³ Similarly, the COVID‐19 pandemic stoked xenophobic responses targeting Asian immigrants and Asian Americans. ⁶⁴ , ⁶⁵

Reflecting global patterns, the United States has seen political polarization of immigration attitudes, with a vocal and mobilized minority favoring restrictive and punitive immigration policies. ⁷⁵ , ⁷⁶ Polarized attitudes regarding migration and immigrants have implications for immigration policies. For example, from 2016 to 2019 there was declining support among Democrats for further construction of a wall along the US‐Mexico border, a major policy platform and media spectacle under the Trump administration. ⁷⁷ Conversely, among Republicans, support for the border wall increased from 63% in 2016 to 82% in 2019. ⁷⁷ However, more than being a purported solution to immigration concerns, the border wall instead serves as a symbolic separation to stoke social division.

Historically and during the COVID‐19 pandemic, infectious disease narratives have been used to amplify anti‐immigrant policies and practices. ²¹ During fiscal year 2021, the US Border Patrol turned away immigrants at the border approximately 1.6 million times. ⁷⁸ Simultaneously, the United States experienced an increase in hate crimes against people of Asian and Pacific Islander origin or descent, with more than 9,000 incidents of anti‐Asian and Pacific Islander hate reported from March 19, 2020, to June 30, 2021. ⁷⁹

Organizing strategies and public engagement in immigration advocacy seen in the Obama and Trump administrations have taken different shapes under the Biden administration and appear to largely be carried by long‐standing immigration advocates, even though the Biden administration has continued several exclusionary immigration policies and practices. ⁸⁰ At question is whether immigration policy advocacy has diminished during the Biden administration, and if so, under what conditions. ⁸¹ For example, was there an actual shift in immigration ideology that contributed to large‐scale and sustained immigration advocacy under the Trump administration? What is the general public's perception regarding the effectiveness of policy advocacy strategies for shaping inclusionary federal and state‐level immigration and immigrant policies?

Immigration and Immigrant Policies

Successes in Immigrant Inclusion and Health. There are modest advancements in terms of expanding rights for immigrants that are linked with improvements in population health, particularly in the area of executive or administrative actions. Change in these policies has been the result of immigrant organizing and power building. The most notable inclusionary immigration action in the United States in the early 21st century is the DACA program, ⁸² which grants temporary protection from deportation for young people who migrated to the United States as children. This program was implemented as an executive action by President Obama following sustained advocacy, protest, and civil disobedience by organized immigrant youth. The DACA program, however, is temporary in nature and the Trump administration attempted to rescind it. More recently, the DACA program has been made into a federal rule, providing increased permanency of this program. DACA conferred protected status to 822,000 young people in the United States between August 2012 and July 2019, 9% of whom went on to obtain LPR status. ⁸³ As of December 2021, there were 611,470 active DACA recipients. ⁸⁴ DACA facilitates economic stability, educational opportunities, and access to health care, ⁸⁵ which, in turn, confers salubrious benefits including improved mental health among DACA recipients and their children. ⁸⁵ , ⁸⁶ , ⁸⁷ , ⁸⁸

The 2009 removal of bans on migration for persons who are living with HIV and the reduction in scope of physical exams as an entry requirement under the Public Health Service are important achievements that move away from ableist immigration policies and move closer to respecting the dignity of immigrants. ⁸⁹ While these are important achievements in the immigration policy landscape, these recent gains are fragile and largely dependent on the priorities of the president and party in power.

In the context of entrenched and restrictive federal immigration policies, numerous states and local jurisdictions (e.g., county, city) have developed and implemented immigrant policies and programs to mitigate the impacts of restrictive federal policies or foster more inclusive environments. While state and local actions cannot undo the fundamental restrictions of federal immigration policies, they can modify the impacts of exclusionary laws and, by extension, their health impacts. Key policy domains that have been addressed at the state level include health care access and quality (e.g., extending state health coverage to children or pregnant people regardless of legal status, allowing undocumented adults to participate in state insurance exchanges); education access and quality (e.g., in‐state tuition for undocumented students); labor and employment (e.g., prohibiting employers from using the federal E‐Verify system); and policing and law enforcement (e.g., offering driver's licenses regardless of legal status; declining requests or agreements for local law enforcement to detain people for transfer to deportation proceedings) (See Table 1). ⁹⁰ Inclusive state policies have been linked to reduced inequities in immigrant and Latino health care utilization, ⁷² mental health, ⁷³ and health insurance coverage. ⁷⁴ , ⁹¹ At the local level, some counties and municipalities have also enacted inclusionary policies, including health care access programs that provide preventive and urgent care regardless of legal status, so‐called sanctuary policies to limit local law enforcement collaboration with immigration authorities, and local government‐issued ID policies. ⁶⁶ , ⁹² , ⁹³ , ⁹⁴ , ⁹⁵ Nongovernmental efforts can also take steps to mitigate the impacts of restrictive policies, such as private sanctuary networks, local immigration enforcement response teams, mutual aid and nongovernmental relief efforts, ⁹⁶ immigration bail funds and legal assistance to detained immigrants, ⁹⁷ and nongovernmental photo ID programs. ⁹² , ⁹³ , ⁹⁸ There is a need for more research on the health implications of local and nongovernmental efforts at immigrant inclusion. Although state, local, and nongovernmental programs cannot change eligibility for federal benefits or prevent a person from being subject to federal immigration enforcement or deportation, they may partially limit the extent to which structurally racist federal policies affect the health and well‐being of immigrants and their families.

Failures and Continuing Problems. In the United States, the role of structural racism in shaping the experiences and health of immigrant communities is apparent when looking at 21st‐century shifts in federal immigration policies. While the fundamental nature of exclusionary immigration policies as a form of structural racism has not changed, the strategies have evolved with each change in presidential administration and political party in power, aligning with the reality that for racism to maintain a stronghold, it must adapt and evolve. ²⁴ , ²⁷ , ²⁹ , ⁹⁹

Post‐9/11 politics have transformed the US approach to immigration, contributing to a restructuring and substantial augmentation of immigration enforcement agencies and priorities. ¹⁰⁰ , ¹⁰¹ For example, the Immigration and Naturalization Services was dissolved and the Department of Homeland Security was created, moving away from prioritizing naturalization processes to prioritizing the militarization of responses to immigration, which are now treated as a threat to “homeland security.” ¹⁰² Post‐9/11 administrative and policy changes multiplied the impact of a suite of policy changes from the mid‐1990s, including the Antiterrorism and Effective Death Penalty Act and the Illegal Immigration Reform and Immigrant Responsibility Act, resulting in a massive expansion of the immigration detention and removal apparatus. ¹⁰⁰ , ¹⁰³ , ¹⁰⁴ Additionally, several post‐9/11 policies such as the Real ID Act of 2005 and the PATRIOT Act of 2001 are important immigrant policies that increase barriers to accessing health‐relevant resources, such as government‐issued IDs and financial resources for immigrant communities, respectively. ⁹²

Despite significant advocacy, the United States still has not achieved a path to citizenship that is not contingent on increased border or interior enforcement and other exclusionary immigrant policies at the federal level. During this same period, there has been a proliferation of the US immigration surveillance system through the expansion of electronic monitoring and technologies that are used as alternatives to detention (e.g., ankle monitors) that are stressful, invasive, painful, and exclusionary. ¹⁰⁵

Alongside the growth of border enforcement and detention apparatuses, interior immigration enforcement has also increased. One notable example is the revitalization of immigration raids, coordinated and often militarized enforcement actions by which immigration agents make any number of immigration arrests, often in coordination with other law enforcement agencies. The resurgence of worksite raids during the Trump administration built upon a model that was advanced under the George W. Bush administration, and historical and ongoing exploitation of low‐wage immigrant workers in agricultural and food and other processing industries. ⁵ , ⁹

Although there have been some important, yet fragile immigration policy wins in the early 21st century, federal immigration policy remains infused with racism. Despite the implementation of the DACA program, President Obama became dubbed “Deporter‐in‐Chief” for scaling up the interior and border immigration enforcement schema developed by Democratic and Republican predecessors to deport more than 1.9 million immigrants from the United States. ¹⁰⁶ , ¹⁰⁷ , ¹⁰⁸ Obama also led the passage of the Affordable Care Act, which was the most recent large‐scale federal immigrant policy as it systematically excluded immigrants from eligibility for health insurance expansions. ³⁷ The political campaign that laid the foundation for the Trump administration began by centering “othering” messages about Mexican immigrants and with promises to build a border wall and detain and remove undocumented immigrants. ⁷⁰ The Trump administration deported more than 1.5 million immigrants, began a process of building the border wall, notoriously separated minor children from their families, implemented wide‐scale immigration raids, and challenged the DACA program. With the change in presidential administrations in 2021, there was hope that immigration policies would improve. ¹⁰⁹ Yet, under the Biden administration, we have seen the continuation of mass deportation efforts, with 622,832 deportations as of February 2022 and 312,174 new deportation proceedings during the 2021 fiscal year. ¹⁰⁸ , ¹¹⁰

The growth in deportations in the early 21^st century at the discretion of each presidential administration are made possible, in part, by federal immigration policies, discussed earlier, that have contributed to the substantial growth of immigrant detentions. ¹⁰⁰ The growth of the immigrant detention industry has contributed to the proliferation of corporations and so‐called nonprofit organizations that are motivated to maintain the status quo by finding ways to profit off of incarcerating and/or detaining people. Private prisons, which detained approximately half of immigrant detainees in 2015, have proliferated over the past several years due, in part, to the millions they spend on lobbying efforts. ¹¹¹ , ¹¹² Alongside the growth of immigrant detention systems and border and interior immigration enforcement is the growth of the Immigration and Customs Enforcement (ICE) and Customs and Border Protection unions, ¹¹³ , ¹¹⁴ , ¹¹⁵ which are increasingly sought after for endorsements by political candidates, highlighting the deepening entanglement between elected officials, policymakers, and the immigration enforcement and immigrant detention industry.

Private hospitals also contribute to this expansive system through medical deportations. ¹¹⁶ Hospitals can and have initiated and paid for the costs of deporting un‐ or underinsured undocumented immigrant patients with critical injuries or illnesses. ¹¹⁷ Medical deportations do not require coordination with immigration authorities, constitutes a breach of ethical codes of medical practice, and affirms some immigrant communities’ mistrust of health care and public health institutions. ¹¹⁷

Public Health Research

Successes in Immigrant Inclusion and Health. Within the context of these changes and ongoing challenges in societal values, beliefs, and practices and immigration and immigrant policies, research on health and well‐being of immigrant communities increasingly takes a structural lens, above and beyond cultural and behavioral explanations of health. ⁴ , ⁶ , ⁷ , ⁹ , ¹⁰ , ¹¹ , ²⁰ , ³⁸ , ¹⁰⁹ , ¹¹⁸ , ¹¹⁹ , ¹²⁰ An important advancement in public health scholarship is the general consensus that immigration policy is health policy. ¹⁰ , ¹²¹ Structural approaches are becoming increasingly more sophisticated, both conceptually and methodologically. Conceptually, public health scholarship is integrating theoretical perspectives from social sciences and legal scholarship to deepen understanding of the interconnections between racism, xenophobia, immigration, immigration policy,immigrant policy, and health. This is evident in the growth of intersectional analyses that elucidate how racism and citizenship stratification shape health. ⁷ , ³⁸ , ¹²² US‐based scholarship regarding immigration and immigrant health is most developed in the area of Latino immigrant health, particularly the health of Mexican‐origin immigrant communities. ⁷ , ⁸ , ⁴⁹ , ¹¹⁸ , ¹²³ , ¹²⁴ There is growing scholarship focused on enhancing understanding of the experiences of subgroups of immigrants, including African, Asian, Pacific Islander, and Arab immigrant communities. ⁵² , ¹²⁵ , ¹²⁶ , ¹²⁷ , ¹²⁸ , ¹²⁹

There is growing acknowledgment that policing—including immigration enforcement and local law enforcement actions—is inimical for health. Indeed, the American Public Health Association (APHA), the organizing body for the field of public health, has classified law enforcement violence as a public health issue. ⁸⁷ Moreover, APHA has called for inclusionary immigrant policies, such as access to housing subsidies and other public safety‐net programs regardless of legal status, publicly denounced immigration policies and practices that separated immigrant families at the southern US border, and called for investigation and prevention of sexual and reproductive rights violations in immigrant detention. ¹³⁰ , ¹³¹ , ¹³² , ¹³³

A number of important methodological advancements in the study of immigration and immigrant policy and health hold promise for other domains of public health research. A particular area of improvement pertains to the measurement of federal immigration policies and federal, state, and local immigrant policies. Numerous studies have moved the focus of analysis from immigrants’ and their individual behavioral choices to document and categorize the range of public policies that may influence immigrants’ rights and access to opportunities. ⁵⁴ , ⁶⁸ , ⁷³ , ⁹⁰ By advancing measurement of policies themselves, this area of research recognizes how immigration and immigrant policy produce structural and interpersonal discrimination. Evidence from these studies show that states and localities with more anti‐immigrant policymaking have greater health inequities between immigrants and nonimmigrants, as well as between people of color and whites. ² , ⁵¹

Failures and Continuing Problems. There are several areas of needed growth for public health research and practice regarding immigration and immigrant policies and health. First, although public health scholarship has increasingly incorporated a structural understanding of factors that shape the well‐being of immigrant communities, dominant paradigms of cultural explanations of health (e.g., acculturation) and white supremacy (e.g., what if detention was justified?) remain common among manuscript and grant reviewers. ¹³⁴ Additionally, there are significant institutional barriers to advancing scholarship regarding immigration and immigrant policies and health, such as the pursuit of public funding (e.g., National Institutes of Health) to study the health impacts of punitive immigration and immigrant policies that stem from the priorities and behavior of governmental institutions that also determine research priorities and budgets.

There is an urgent need to study the experiences of immigrant communities within other countries. Federated regions, such as the European Union, have restrictive border policies similar to those of the United States; nations across Europe, as well as in other North American countries and Australia, have, like the United States, linked policing with immigration enforcement. What are the health implications of these policies? We echo long‐standing calls for transnational scholarship regarding immigration policies and health, ¹¹ such as those that center the experiences and impacts of deportation and hardening national borders on home and return communities outside of the United States. Further, the rise of climate migration calls for a need to understand the impact of climate change, migration, and dynamics in home and destination countries or regions on health.

There remains an important need to translate public health research regarding the health implications of immigration and immigrant policies to inform the development of inclusionary immigration and immigrant policies, and to study the extent to which this growing area of scholarship has informed policy debates and the passage of inclusionary policies. Despite recognition that immigration and immigrant policies are health policies, the field of public health is very cautious about establishing immigration policy platforms or engaging in immigration advocacy. Toward this end, APHA opposes the separation of immigrant and refugee families at the southern US border and the incarceration of immigrant children in detention centers. ¹³² , ¹³⁵ However, APHA does not have a policy platform regarding deportation in particular.

Potential Solutions: Policies, Strategies, and Practices

As we cast forward to potential solutions to promoting the health of immigrant communities through structural interventions, several strategies are needed. Our recommendations include building coalitions of stakeholders who are unified across multiple forms of oppression; designing and implementing inclusionary federal, state, and local policies that attend to both direct and indirect impacts on the structural drivers of health for immigrant communities; advancing public health scholarship focused on overlooked and emerging issues affecting immigrant health; and translating research to inform upcoming national and state policy platforms and electoral politics. In this section, we elaborate briefly on these solution areas.

To truly promote the health and well‐being of immigrant communities, we need to center immigrant communities in leadership, policy decisions, policymaking processes, practice, and research. To center impacted communities, it is critical to invest in and directly support the work of immigrant‐led community‐based advocacy efforts, such as community‐organizing strategies, coalition building, and mutual aid. Given the power of narratives, it is important to improve representation of immigrant stories in the media and highlight and support the work of artists and writers of color who are advancing projects related to immigration and immigrant issues, with a particular focus on youth‐centered storytelling strategies.

In the policy domain, the time is now for creating a fair and direct path to citizenship for immigrants in the United States. Given the growth of exclusionary and restrictive immigrant policies that shape the day‐to‐day opportunities and experiences of immigrant communities, it is important to create more inclusionary immigration policies, particularly at the federal level. Additionally, local‐level advocacy is needed to advance the rights of immigrants and immigrant communities. More institutional support and funding are critical for immigration advocates to advance their cause in ways that are sustainable, foster the development and growth of new systems to protect and support immigrant communities, and enable them to care for their own well‐being as well.

Relatedly, although the United States is becoming a minority‐majority society, in the field of public health researchers remains predominantly white. ¹³⁶ , ¹³⁷ The field must prioritize and invest in training, recruiting, and retaining more scholars who are first in their family to attend college, identify as immigrants or from an immigrant community, and/or identify with other historically oppressed groups. Building pathways to diversify public health research necessitates supporting students and early‐career professionals from immigrant backgrounds.

Finally, there is a need for public health scholars to recognize the centrality of advocacy as part of the public health research process. As a field, we need to build priorities and science around translating new public health knowledge regarding immigration and immigrant policies to inform advocacy and policy change. Current gatekeepers in public health (few of whom represent communities of immigrants or people of color) reflect discomfort with overtly abolitionist, anticapitalist stances on immigration and immigrant issues. Yet, these approaches are necessary to achieve health equity.

Conclusions

The field of public health has incorporated a growing understanding of how structural factors shape the well‐being of immigrant communities, with particular gains in localized approaches to promoting the inclusion and health of immigrant communities. Yet, we argue that overarching gains in national, state, and local policies, practices, advocacy, and research are precarious and characterized by setbacks and protracted inaction on inclusionary immigration and immigrant policies. To promote the health of immigrant communities and generations to come, there is an urgent need to create pathways to citizenship, invest in community‐driven strategies to support immigrant communities, and strengthen public health research processes to deepen understanding of and address structural drivers of immigrant health inequities.