Are the Undocumented Deserving? Health Workers’ Views of Immigrants in Alabama

Abstract

Undocumented immigrants are ineligible for many public benefits and often rely on safety- net clinics, such as community health centers, for health care. Using in-depth interviews, we explored attitudes about undocumented immigrants’ deservingness of health care among staff and professional health workers (n=31) at two safety- net clinics in Alabama, which passed a restrictive immigration law in 2011. We used content analysis to examine frequently used frames to describe health deservingness. Overall, a total of 27 frames were used by health workers. They most frequently justified their views using frames of medical humanitarianism (i.e., health workers should care for those in need) and equality (i.e., people should not be treated differently from one another). Several respondents used multiple, conflicting frames that simultaneously supported and questioned immigrants’ deservingness of care. The diverse ways in which health workers in this sample framed undocumented immigrants’ health deservingness may affect provider-patient interactions.

Around the world, many currently debate who is and who is not deserving of health-related investment and care.^1–7 These debates are especially important for the estimated 20–30 million undocumented, or unauthorized, migrants worldwide.⁸ In the United States, an estimated 11 million undocumented immigrants are not eligible for many federal public benefits, although exceptions are made for medical emergencies and certain public health programs (e.g., immunizations).⁹ Furthermore, the 2010 Patient Protection and Affordable Care Act (ACA), which began to change the U.S. insurance system from one based on exclusionary models towards one that ensured almost all Americans could obtain health insurance, explicitly excluded undocumented immigrants from participation.^10–11 Not only did undocumented immigrants remain ineligible for Medicaid, they also were barred from receiving subsidies to purchase insurance on the marketplace. A consequence of these policies is that while previously uninsured populations before ACA are now insured, undocumented immigrants remain barred from participation.^11–12 Such exclusion carries ethical, experiential, and epidemiological consequences.¹³

Central to discussions underlying these policy decisions is whether undocumented immigrants are deserving of health-related investment and care. While deservingness has been extensively explored in the welfare literature, much less is known about health deservingness.^1,13 Health deservingness is different from formal entitlements to health, which carry legal stipulations that make up certain public benefits, including health care. Instead, deservingness is rendered by ethical decisions and moral assessments. These assessments are often conditional, relying on perceived or actual characteristics of an individual or group and being influenced by social, cultural, political, and economic contexts.¹ Indeed, the theoretical groundwork for the mass feedback effect asserts that public policies have important influence in the “social construction of target populations” by generating “the cultural characterizations or popular images of the persons or groups whose behavior and well-being are affected by public policy.”¹⁴ These characterizations affect how public officials respond towards these groups.¹⁵ Furthermore, factors of program administration (i.e., program structures, routines followed by administrators and recipients, and organizational cultures) have been shown to have interpretive effects that generate feelings of deservingness and influence political engagement.¹⁵

For example, Horton’s research has demonstrated that the state’s characterization of political as opposed to economic immigrants has profound implications in the clinical setting.¹⁶ In the context of economic instability and a declining welfare state in New Mexico, hospital staff and administrators portrayed undocumented Mexican immigrants as undeserving of resources because of the perception that they do not pay for their medical costs and thus represent a drain on public benefits. Immigrants that were a part of the Cuban Refugee Program, on the other hand, were portrayed as a resilient and hardworking group who had earned their right to government assistance. The implications of the differential construction of deservingness of these two groups were profound: undocumented immigrants experienced delays in care and were subject to pay-up-front policies and even deportation. Ultimately, while Cubans were encouraged to become involved in civic institutions, Mexican immigrants were discouraged from accessing health care benefits and assuming active civic roles.¹⁶

Contemporary research methods in cognitive anthropology investigate the ways shared cultural knowledge is “constructed, organized, and distributed among members.”^17(p.347) One way of getting at this distribution of knowledge is to investigate schema and the frames that organize them. Schema are general outlines of the world, or some part of it, composed of experience and stored in memory.¹⁸ People share schema based on common experience and according to Quinn,¹⁸ result in a common culture or subculture. These schema can be discovered through analyzing conventional discourse or frames, which “provide readily grasped, simplified mental and verbal representations that are easy to think and say. They are mental shortcuts and verbal signaling devices. Repeating them helps determine what will be taken to be the conventional wisdom in an opinion community”^.19(p.268) Strauss argues that the formulaic aspects (in form and content) of conventional discourse suggest that they are learned from others and are therefore shared.¹⁹

Immigrants’ health deservingness has been framed in different ways by various stakeholders and by immigrants themselves.^20,21 A widely recognizable frame is one that casts undocumented immigrants as “illegal aliens,” presupposing unlawful behavior and rule violation.²¹ By criminalizing their migratory behavior, the state justifies its efforts to restrict undocumented immigrants’ access to health care. The condition of “illegality,” then becomes a risk factor for immigrants’ health, social vulnerability, and abuse across contexts.^2,22,23 Indeed, studies have demonstrated how being classified as “illegal” can engender feelings of fear, humiliation, disrespect, and ridicule; these feelings can occur concomitantly with other forms of exclusion, including stigma, denial of health care services, and discrimination.^24–26 Furthermore, public discourse that labels migrants as illegal can have a “chilling effect,” which the anthropological literature defines as the voluntary withdrawal of persons/immigrants from health benefits as a result of their embodiment—in both epidemiological and phenomenological senses—of health care undeservingness.²¹ The result can be that they avoid seeking care for fear of deportation or internalize arguments that they do not deserve health care.^2,13,27

Other discursive frames cast immigrants as deserving of health care, regardless of their legal status. These include frames that assert the importance of medical humanitarianism (health workers should care for those in need), equality (people should not be treated differently), health care as a human right, immigrants as deserving because they contribute to American society through their hard work ethic and payment of taxes (“the effortful immigrant”), and a “cost savings” frame based on immigrants’ benefits to society and their low use of health services.²¹ Other frames define deservingness more narrowly, such as the maternalistic frame, which endorses the inclusion of families—specifically immigrant mothers—into the health system as caretakers of American children.²¹

In this study, we explore frames used to describe the views of health deservingness of undocumented immigrants among health workers at two safety- net clinics in Alabama, a state that has extended federal limits on undocumented immigrants’ access to health care through passage of restrictive legislation. We focus on safety- net hospitals and clinics because they are the major providers of health care for undocumented immigrants, and health workers at these institutions are considered to be the primary “street-level bureaucratic arms” of local governments.^10(p.848) Although safety- net health workers are likely influenced by federal and state health policies and bureaucratic processes, they have some discretion in interpreting, enacting, and enforcing government policies in their work.^10,28,29 By examining these views, we are able to contextualize interactions within health care settings that may affect immigrants’ access to or use of health services.

Methods

Setting.

In 2011, the Alabama state legislature passed House Bill (HB) 56, which was described at the time as the strictest immigration law in the nation.³⁰ Although this bill does not include language restricting support or incriminating health workers providing care to undocumented immigrants, it does require proof of lawful U.S. residence to receive state and local public benefits, except those protected by federal laws; protected benefits include prenatal and emergency care, child and adult protective services, and other services (i.e., immunizations; the Special Supplemental Nutritional Program for Women, Infants, and Children [WIC]; and short-term disaster relief ).^31,32 This bill casts undocumented immigrants as “illegal aliens” undeserving of governmental health benefits.³³ Alabama’s House Bill 56 (in this respect like the otherwise dissimilar 2010 Patient Protection and Affordable Care Act [ACA]), creates symbolic, social, and empirical exclusions for this population.¹⁰

We recruited participants from two safety- net organizations: a federally-qualified health center (FQHC) and a county public health department (PHD). The FQHC provides comprehensive primary care services, including dental care and HIV/AIDS care, and offers services that improve access to care such as interpretation, case management, and transportation services. Medicaid and WIC offices are co-located at the FQHC, allowing eligible clients to enroll for services on-site. This non-profit health center is open to all residents regardless of citizenship status, insurance status, or ability to pay, and serves a diverse population of low-income, uninsured, and racial/ethnic minority patients. The PHD provides family planning services, children’s dental care, and testing and treatment for infectious diseases; Medicaid and WIC offices are also co-located at this site. Undocumented immigrants are eligible for select services at this clinic depending on the reason for seeking care (e.g., immunizations) and the funding source.

Procedures.

Participants were identified primarily through snowball sampling between November 2016 and January 2017 and interviewed using a semi-structured interview guide. A preliminary interview guide was pre-tested on seven health care workers from a public hospital and private clinic. The guide included questions about general experiences working in health care, experiences with immigrant health care, and perceptions of health deservingness of undocumented immigrants in general and undocumented pregnant immigrants specifically. We also collected information on participants’ demographic characteristics (i.e., age, ethnicity, gender) and occupation within the clinic. The term “undocumented” was used in interviews to refer to individuals who live in the United States without legal status. While other terms, like “unauthorized,” are used to refer to this immigration status, “undocumented” was selected because it was thought to have a clear meaning.

All participants gave written informed consent and were compensated for their time with a monetary award of $10. The first author took extensive notes during all interviews, and interviews were audio-recorded with participants’ permission. Several informants (n=5) declined for their interview to be audio-recorded. Interviews lasted between 26 and 90 minutes.

All audio-recorded interviews were transcribed. The first author coded all transcripts and other interview notes for discursive frames. Use of a single coder is consistent with interpretative social science tradition in which the person who conducted the interviews is best suited to analyze the data because s/he had access to other data and information (e.g., non-verbal communication and social context). Any discrepancies were reconciled through joint review by the first and second authors. Framing analysis has been used by cognitive and linguistic anthropologists, along with other social scientists, to explore the social production of conventional discourse.³⁴ Such discourse acts as a cognitive and rhetorical scaffold allowing speakers to talk without a great deal of thinking through their stances from scratch.^19,35 The formulaic aspects in form and content of conventional discourse suggest that they are learned from others and are therefore shared.¹⁹ The frames identified in this study were classified as either “frames of deservingness” or “frames of undeservingness.” Frames of deservingness were classified as such if they described immigrants as deserving of health care in some way (e.g., medical humanitarianism, maternalistic justification), while frames of undeservingness explicitly placed limits on that deservingness (e.g., illegality).

We hypothesized that a medical humanitarianism frame would be more frequently used among health workers at the community health center, while public health’s focus on infectious disease control and surveillance would lead to more frequent use of an infectious disease frame among health workers at the public health department. We used IBM SPSS (IBM Corp. IBM SPSS Statistics for Windows, version 24.0. Armonk, NY: IBM Corp, 2016)) to determine the frequency of frame use and to test the hypothesis about difference in frame use by participants at the FQHC and PHD. We also compared frame use by occupation (dichotomized into staff and professional), ethnicity, and time worked at the clinic

All names and identifying characteristics of individual participants have been changed to ensure anonymity. Pseudonyms were selected from a list of most common names in the United States. The study protocol was approved by each clinic administration, the state department of public health, and the institutional review board of the University of Alabama.

Results

Participants in this study included 31 staff and professional health workers: 16 from the FQHC and 15 from the PHD. Of the 31 health workers interviewed, 28 were women (Table 1). The majority of health workers (n=21) self-identified as African American; six were White and three were Hispanic. Just over half worked in staff positions, including clerks (n=7) and clinical assistants (n=11).

Table 1.

GENDER, ETHNICITY, AND OCCUPATION OF HEALTH WORKERS AT EACH CLINIC

	FQHC n (%)	PHD n (%)	Total n (%)
Gender
Female	13 (81)	15 (100)	28 (90)
Male	3 (19)	0 (0)	3 (10)
Ethnicity
African American	12 (75)	9 (60)	21 (68)
White	2 (13)	4 (27)	6 (19)
Hispanic	2 (13)	1 (7)	3 (9)
Other	0 (0)	1 (7)	1 (3)
Occupation
Staff	12 (75)	6 (40)	18 (58)
Clerk	2	5	7 (3)
Clinical assistant	10	1	11 (36)
Professional	4 (25)	9 (60)	13 (42)
Social service coordinators	1	8	9 (29)
Institutional resource managers	2	0	2 (6)
Clinician	1	1	2 (6)
Total	16 (51)	15 (48)	31 (100)

Notes:

FQHC = Federally-Qualified Health Center

PHD = County Public Health Department

Overall, study participants used a total of 27 frames, and 16 of these frames were shared by two or more health workers (Table 2). Most participants (n=23) argued for the health deservingness of undocumented immigrants. Medical humanitarianism and equality were the most commonly used frames, followed by preventive care, golden rule, risks associated with pregnancy, infectious disease, and health as a human right. Frames of medical humanitarianism and infectious disease emerged with similar frequency among both FQHC and PHD participants; therefore, we present results for health deservingness across all categories of respondents.

Table 2.

FRAMES USED BY TWO OR MORE HEALTH WORKERS TO DISCUSS UNDOCUMENTED IMMIGRANTS’ HEALTH DESERVINGNESS.

Frame	n	Representative participant quote
DESERVING
Medical humanitarianism	26	It’s the job of the health worker to care for people who need care.
Equality	21	Because they’re humans. We’re all human.
Preventive care	8	Regardless of where they come from or how they got here, if you can help em with whatever illness it is or help them prevent them from getting a certain illness or disease, not the fact that, well you ain’t from the US so we don’t need to help you.
Golden rule	7	I try to do extra for them because I think if I was in their situation in their country and I’m getting something done, I would want someone to be nice and help me, you know?
Risks of pregnancy	6	While they pregnant, it should be some different diseases that can come along, possibly while they’re pregnant, like gestational diabetes, something going wrong with the baby.
Health as right	5	Even though they’re undocumented, I feel like they still need help and they should have rights even though they’re not citizens.
Infectious disease	5	I know that it’s a high case of tuberculosis in Hispanics, so if they’re not seeking any type of health care, then that just makes things worse.
Not the child’s fault	4	The children didn’t ask to be here, they’re brought here because of an adult of course.
Contributing to system	4	But they’ll pay you, it’s like I have money, here, it’s not that many that really come in with no money and no intent of paying.
Infant as human	3	Yeah because regardless whether the fact whether the person is documented or not documented, that’s a human life that they’re carrying.
Establishment	3	To feel more comfortable and to just know that they have like a hopefully a safe haven and maybe some way that they can establish some type of support, you know, networks and support systems, and then who knows from there what it could evolve into.
Cost-effectiveness	3	From a cost-effective standpoint for medical resources, earlier access to care will prevent expenses down the line.
Maternalistic frame	2	You should be about the unborn baby that the person is carrying, because the pregnant mom herself may be undocumented but once she gives birth to the baby, it’s in Alabama. That makes that baby a citizen here.
UNDESERVING
Illegality	5	See when you’re undocumented, you can’t be on the same level, ‘cuz you, you workin—it’s illegal. It’s just illegal all the way around.
Health as commodity	3	I’m one of those people that health care’s not a right. But it should be available, but then people need to be accountable as well. And it goes both ways you know, it’s one of those, if you’re needing access, and you should be able to come in and be provided the care you need, but then you also need to pay for it.
Excess reproduction	2	They come in, some are pregnant with one, they have one or two walking then they totin’ one. I don’t understand why they want to have multiple babies like that. It’s just so many. And I mean, you already strugglin’.

Participants frequently used more than one frame when explaining why undocumented immigrants were deserving, and professionals used more frames to describe health deservingness than staff (professional $\overline{\text{x}}=4.6$; staff $\overline{\text{x}}=3.2$; t= −2.124; p=.042). For example, Ashley, a professional at the public health department, used medical humanitarianism and equality frames when she explained why it was important that undocumented immigrants were included in the health system:

Because we’re human beings. Because we’re all human beings, because how we treat others matters. And there’s nobody that’s greater or less than anyone else. Whatever the wealthiest deserves, the poorest deserves as well … That’s why.

Elizabeth, a staff worker at the FQHC, also framed health deservingness using both principles of humanitarianism and equality:

Treat them the same. Although we do know they’re illegally here, but still, why treat them different? They just over here to make a life and a living just like we are … why, you know, make it difficult to them when they still, they over here, they need health care.

She later elaborated on her medical humanitarian views:

Every situation is going to be different, but still, you handle each situation the same. I mean, you just, you’re there to help, no matter what. So, that’s just how I look at it. This is my job, I’m here to help you. So let’s figure this out.

Medical humanitarianism and equality were invoked among respondents who also used other frames to describe health deservingness. Seven of the eight participants who discussed the importance of preventive care simultaneously emphasized medical humanitarianism and equality. This was again exemplified by Ashley, who stated:

There certainly should be a way that maternity care is paid for. Because like I said … it’s about babies that are gonna grow up with these terrible birth defects that had the mom been given folic acid, could have been prevented.

Similarly, all participants who used the golden rule frame–which stressed experiencing a reversal of roles-did so in conjunction with medical humanitarianism. Karen, a staff worker at the FQHC, stated:

Everyone deserves an opportunity to be seen, you know, like, especially with health, ’cuz that’s something you can’t, you know, if it gets out of hand and you die, you only have one body. So I think everybody needs the opportunity to–for their bodies to be taken care of, especially if they, if they’re reaching out, you know, with a need. And if it was, you know, if it was, the shoe was on the other foot, we would want to be seen, have those resources.

Six participants emphasized deservingness based on perceived risks of pregnancy. Kim, a professional at the PHD, described pregnancy as an exceptional condition based on a woman’s perceived risks:

If they have a cold, maybe they can figure it out, just because there’s other people, whether they’re documented or not documented that don’t have insurance that have to deal with the same kinds of issues. But I just think pregnancy there’s just too many things that can happen and go wrong that can cause so many health problems for both the mother and the child.

Thus, pregnant women were seen by some as deserving of health services based on pregnancy-associated risks that may affect mother and child. Other frames used to argue for pregnancy-health related deservingness included emphasizing that infants are humans too (n=3), describing the mother as the caretaker of a future citizen (n=2) (i.e., the maternalistic frame), stressing the importance of prenatal care to the quality of life for the mother and child (n=1), and highlighting that there are two lives at stake (n=1) (Table 2).

The infectious disease frame was used by five health workers, including one health worker from the FQHC and four from the PHD. This frame was used exclusively by participants in staff positions. Betty, a resource manager at the FQHC, said:

I think everybody needs to be treated the same, they should have the same availability to care if we’re gonna affect our outcomes and you know, have preventive things even with things like immunizations because there’s other diseases and things that we can prevent and a lot of ‘em may not be aware of that.

Health was described as a human right by five participants, four at the PHD and one at the FQHC. Stephanie, a public health professional, stated that undocumented immigrants “should have rights, even though they’re not citizens” because “they need care.”

Conflicting frames.

Although the majority of participants reported that undocumented immigrants were deserving of health care, several made comments that implied limits to deservingness. Barbara, a staff worker at FQHC, also framed health care as a right, yet she described how and when this right might be withheld:

I know we got amendments and rights, and I’m not tryin’ to say nothing against, like going against what our rights are, ’cuz everybody have a right. But what I’m sayin’ is … it should be a limit on how many times you can, we gon’ pay for you to have a birth, and if you start makin’ ’em pay it out the pocket, then I think you’ll see a big difference.

Barbara’s statement sheds light on how health workers used frames to both support and question health deservingness. Altogether, eight health workers (5 professional, 3 staff) used multiple frames in this manner. Concerns over the costs of health care–and who pays for whom–factored into these arguments of ambiguous deservingness. For instance, Robert, a clinician at the FQHC focused on the financial and social constraints on the health system, which are at odds with his personal views of treating everyone:

We have a large Hispanic population, and that’s largely where our undocumented immigrants come from, and we need to be as a health care system prepared to deal with that. So yes, access needs to be explained … we need to be set up to deal with navigating undocumented immigrants through the system, or finding, you know, ways in which they can pay for care or get the specialty services that they need if they need them … The other part is you know, it’s one of those double-edged swords because our jobs … as a health care place is not to police the borders …

In the same token … our health care system isn’t set up to treat everybody because there is a finite amount of money, and if you’re not contributing into that system, at some point the system will break down, and as it is we’re already overtaxed as a medical community. There’s not enough physicians, there’s not enough nurse practitioners, there’s just not enough resources to … simply to just give out. And so it’s difficult from a state standpoint versus a personal kind of standpoint. There are two different issues, so I can understand the dilemma.

When asked later in the interview about his ideal health system, he answered that, “The same health care system should be one that respects people of all cultures and ethnicities, where again their job isn’t to say who can be treated but to treat whoever presents for treatment.”

Some health workers focused on the perceived financial resources and behaviors of undocumented individuals themselves. These included perceptions of immigrants as taking advantage of taxpayers, which seemed to undermine frames of deservingness. For example, Susan, a staff worker at the FQHC stated:

Because in the type of field we’re in, and like this clinic, it is based on income and based on what you pay, but who pay for the services? The taxpayers. They have to come out of pocket and … if they’re not documented, it’s like, we’re payin’ for ’em and they’re payin’ nothing.

Susan’s sentiment was shared by another health worker in this study, also a staff worker at the FQHC. However, Susan later expressed humanitarianism when she said, “I think everybody deserve help though. I don’t think they should get turned away.”

James, an institutional resource manager at the FQHC, also expressed conflicting frames of the health-related deservingness of undocumented immigrants. James stressed that health and health care were necessary for being productive, contributing members of families and societies, and talked about the importance of preventive care. Still, he stressed that health care was a commodity, stating: “I’m one of those people that health care’s not a right. It should be available but then people need to be accountable as well. You should be able to come in and be provided the care you need, but then you also need to pay for it.” James drew from discourses of patient fiscal accountability and compliance with biomedical standards. At the start of the interview, James noted that the undocumented immigrants he interacted with were “very accountable, self-reliant” people who will “pay you … it’s like I have money. Here. It’s not that many that really come in with no money and no intent of paying.” Similar to three other health workers, all at the FQHC, he positively evaluated undocumented immigrants as paying patients who contribute, in one way or another, to the health system. Yet, in the following excerpt, he provides a narrative for what might happen in the instance of a “proverbial time bomb” ticking in the absence of patient responsibility:

Well, in some cases it’s like everything else. Health care’s not cheap, but it’s necessary. So you have multiple visits during a pregnancy, or should have multiple visits. You may end up having even more visits if you have any sort of complications. So like I said, it’s one of those things you probably, probably the biggest issue is with people that show up that are pregnant ready to deliver, no prenatal care, talk about proverbial time bomb. You have no idea and it may turn out everything’s great and wonderful but then what if it doesn’t? And our society automatically says well, what did the provider do wrong? Maybe it wasn’t the provider, maybe it was the patient. You’ve got people who are pregnant that are still drinking and smoking and doing a lot of unhealthy lifestyle things and they’re not willing to change. They may end up with a child that has some sort of issues. Whose fault is that? It’s not the system.

In this instance, these stereotypes that James expresses are contradictory to the experiences he has had with immigrants.

Five of the health workers who expressed conflicting frames focused on the illegality of undocumented immigrants and two questioned the health deservingness of pregnant women based on perceptions of immigrant women’s excess fertility. Barbara, a staff worker at FQHC stated:

It should be a limit on how many times you can, we gon pay for you to have a birth … if you allow ’em to keep havin’ ’em and we, tax-payin’ hard-workin’ middle cla—ugh not middle class, ’cuz I’m just as poor as a church mouse, uh, then I think we’ll see a big drop in it. … But if you, you’re havin’ ’em for free, you know, you have one this year, this nine months, and three, four months later you’re pregnant again? That’s just, come on now. And they need the stipulations to get these benefits. I’m not tryin’ to control you, it’s your choice, but in order for you to get [benefits], this the birth control you have to have …

This sentiment–of regulating immigrant women’s fertility–was echoed by only one other participant, also a staff worker at FQHC, who suggested that there be a limit to the “regular help” a pregnant immigrant may receive until she can become legally documented. Barbara also described undocumented pregnant women as having “anchor babies.” She stated, “Why you havin’ multiple births if you ain’t legal? Now if you have to go back, are you thinkin’ you can stay because you got all these babies and they are citizens they born citizens. But you’re not. It just ain’t right.” This focus on the “illegality” of undocumented immigrants was shared among five of the health workers who expressed conflicting frames.

Discussion

Among a sample of safety- net health workers in Alabama, which has a recent history of restrictive immigration policies, we found that participants used a wide variety of frames when discussing health care access for undocumented immigrants and that the majority used frames of deservingness to argue for the inclusion of this population into the US health system. Additionally, the types of frames used were largely similar for FQHC and PHD participants. However, we also found that some health workers expressed conflict when discussing deservingness, such that they seemed to argue for the deservingness of undocumented immigrants with limitation.

We have not found a similar treatment of conflicting frames in previous research. Tannen and Wallat examine conflicting frames in the clinical encounter, though frames in their case refers to interactive speech activities (social, consultation, examination) between physician and patient, not to the mental organizing constructs (rhetorical scaffolds) of an individual.³⁶ Barnitt and Mayers hint at this idea in their philosophical discussion of Christianity and humanism as conflicting frames of reference employed by a single occupational therapist, though it is not grounded in frame theory,³⁷ while Price et al. investigated how journalistic story frames can affect the thoughts and feelings of readers.³⁸ A related but distinct concept is found in the business literature: Hahn et al. discussed a paradoxical frame (cf. business frame) in which decision makers consciously weigh the pros and cons of an issue, such as economic, environmental, and social sustainability, where conflicts refer not to intrapersonal ones, but rather differences of opinion among shareholders that must be reconciled.³⁹

Of the 23 frames classified as frames of deservingness, medical humanitarianism was the most common. This suggests that safety- net health workers in this study are united by their compassion and commitment to help those in need. Given that the two clinics share institutional missions to provide medical care for un- and underinsured populations, this result is not surprising and corresponds with research from various other researchers who describe the humanitarianism frame as one that has become dominant in public discourse.^3,20–22

However, anthropologists have challenged the ethical bases of humanitarianism.^40,41 One criticism of humanitarianism is that it can only go so far in an exclusionary health system. As Marrow documents in her research on deservingness of unauthorized immigrants, the local policy environment of San Francisco works to reinforce and encourage public safety- net providers’ views of unauthorized immigrants as deserving of equal care, partly by providing increased financial resources to providers.⁷ However, the Alabama policy climate is embedded within restrictive state and federal health policies. Thus, these “hidden bureaucratic barriers to care” ^(p.847) continue to exist, ultimately limiting public safety- net providers’ abilities to offer equal care to unauthorized immigrants.⁷ In this setting, with undocumented women ineligible to receive Medicaid, an FQHC is essentially their only option in the area for prenatal care if they are uninsured. This gap in prenatal care coverage stands in direct odds with the evocation of pregnancy-care health deservingness expressed by the majority of health workers in this study.

A second criticism leveled against humanitarianism action is that it is discretionary compassion. As Ticktin writes, “Compassion depends on circulating narratives, images, and histories and often on maintaining an unequal power relation between nurse and patient and citizen and foreigner—distinctions that are already heavily gendered and racialized.”^40(p.43–4) Since this compassion is discretionary, it is highly variable between clinics, but also between actors in the same clinic. This has been described as being a sort of lottery: “a chance encounter with a motivated advocate or a compassionate professional.”^42(p.489) Health workers recognized the limits of humanitarianism when emphasizing possible challenges, such as discrimination based on ethnicity or perceived immigration status, that undocumented immigrants might face when interacting with different health workers within their own clinic spaces. Thus, in a single clinic, health deservingness may vary by space and agent.

While the majority of health workers evoked notions of human equality, only five health workers spoke of health as a human right. The formulation of a human right to health has been transformed over the past 20 years, such that it has taken on different meanings in different parts of the world. For example, in Colombia, citizens have utilized the concept of a right to health to oppose reforms that limit access and quality.⁴³ In Chile, the concepts of social justice, solidarity, and equality guide health policy.⁴⁴ In contrast, in the US, the right to health has been adapted to mean a right to consumer choice–of pharmaceuticals, physicians, and health insurance plans.⁴⁵ Castañeda argues that the right to health care is not generally acknowledged in the US system, which is characterized by inequalities.⁴⁶ Instead, she states, “charity and humanitarianism are necessary features that directly result from this system.”^(p.12) Others have documented Americans’ reluctance to articulate health security as a right. In Levitksy’s research, unpaid family caregivers (individuals caring for adult family members with cancer, dementia, or similar chronic diseases) constructed solutions for long-term care management based on models of family responsibility, but struggled to frame long term care provision as a right.⁴⁷ Levitksy attributed this to what she calls “discursive assimilation,”^(p.581) or the process in which new claims may challenge social arrangements but ultimately rely on familiar or existing models of family, market, and the state. The results from the present research echo the conclusions of Castañeda and Levitksy, since few health workers framed health-related deservingness in terms of human rights.

Although infrequently used, we found that public health workers invoked the infectious disease frame somewhat more often than participants at the FQHC, in line with our hypothesis. As mentioned previously, describing undocumented immigrants as vectors of communicable disease who might infect others is not a new concept and likely underlies the fact that access to care to prevent and treat communicable disease is one of the few federal protections that undocumented immigrants have in the US. While the frame does support health deservingness, albeit limited in scope, it also contributes to stereotypes, stigma, and racism directed as immigrants.⁴⁸ Therefore, its use raises the question about whether health workers extend health deservingness beyond infectious disease control. Our analysis revealed that all five health workers using the infectious disease frame simultaneously stressed notions of equality and medical humanitarianism, indicating that they do not solely view immigrants as vectors of disease.

It is also worth calling attention to the different ways in which health workers framed deservingness for undocumented immigrant women. Some participants viewed women as deserving of care during pregnancy because of the health benefits prenatal care would provide to the fetus. This is consistent with the framing of the federal Children’s Health Insurance Program (CHIPS)’s Unborn Child option that considers the fetus the legal recipient of benefits.⁹ Two other participants viewed immigrant women as excess reproducers whose reproductive practices are in need of disciplining. They commented that coverage should be limited if immigrant women have–in their view–too many children who receive publicly supported services.

While this frame was not widely shared, it is not idiosyncratic. Chavez describes how Latina women’s reproductive capacities are surveilled in the United States, where discourses emphasize the reproductive practices of immigrant women as a threat and danger to US society.⁴⁹ This discourse of surveillance of migrant women’s reproductive practices has been documented elsewhere, including Costa Rica⁶ and Italy.⁵⁰

One emergent finding of this research is that several health workers used a combination of frames that, in different parts of the interview, extended and limited deservingness for undocumented immigrants. Half of these conflicted individuals were involved in providing medical care to patients, whether as health care professionals or medical assistants. The remaining four worked in positions outside the exam room. Both within the clinic exam room and outside of it, undocumented immigrants inspired both “compassion and repression” for these eight health workers.⁵¹ For example, in addition to the reproduction-based evaluations mentioned above, a limited health deservingness was based on perceived undesirable immigrant behaviors (e.g., taking advantage of tax-payers, being lawbreakers, or not paying into the health care system). According to these same participants, however, undocumented immigrants were deserving of health because they will pay their bill, have rights to care, and should not be turned away. That frames were used to either extend or limit deservingness at different parts of the interview highlights how frames act as rhetorical scaffolds that allow participants like James and Barbara to use stereotypes to describe immigrant behavior even though they are not consistent with some of their actual experiences in the health care environment.

Internal conflicts over undocumented immigrants’ health deservingness has been documented beyond Alabama. In her exploration of health providers’ views of the deservingness of health care for undocumented Nicaraguan migrant women in Costa Rica, Dos Santos describes discourses that emphasize equality, solidarity, and universality.⁶ Simultaneously, discourse was also characterized as a “rationalized ambivalence”; while health workers described a moral imperative to care for a fetus, deservingness of the mother was contested, with specific rationales employed to justify her exclusion (p. 196). Rationales framed undocumented Nicaraguan women as excessive reproducers when compared with Costa Rican women. This discourse was found among a small portion of health workers (n=2) in this study as well, serving to justify exclusion of undocumented pregnant women. Nicaraguan women were also described as taking advantage of Costa Rica’s jus solis policy, a description reminiscent of the “anchor baby” frame advanced by one participant in this study.

In Vanthuyne et al.’s investigation in Montreal, Canada, health workers described internal conflict over providing full access to health care to “immigrants with precarious migratory status,”^(p.79) specifically uninsured children and pregnant women.³ An online survey constituted one aspect of this research. One-third of the n=1048 respondents who endorsed health as a human right or child development as a priority also endorsed restricted or no access to healthcare services for the uninsured child and pregnant woman. In their further analysis of open-ended questions, approximately one third of the n=237 responses revealed an ambivalence about the health deservingness of migrants in Canada. Unlike in the present research, most of these conflicted health workers opposed a humanitarian principle based on their perception that healthcare resources in Quebec and/or Canada were too scarce. They also expressed concern over the fiscal responsibility of medical care, a frame that was expressed by two health workers in this research.

In Marrow’s research of primary care providers’ views of undocumented immigrants’ health deservingness in San Francisco, participants differed in their degree of support of health deservingness and in the ways they justified their views.⁷ Providers recounted hearing their patients, especially low-income African Americans and documented Hispanics, and more conservative colleagues describe undocumented immigrants as less deserving of publicly-provided medical services than “legal” and “citizen” residents. However, all participants ultimately distinguished their inclusive views from these perspectives, such that although they observed others having internally conflicted views, they themselves were committed to providing care for undocumented immigrants. Our research differs in that not every participant was without internal conflict.

That health professionals used, on average, more frames than those in staff positions suggests that health professionals drew from a great variety of cultural models, including those of health, immigration, and society than staff when discussing health deservingness of immigrant populations. Those with more education tend to have non-overlapping social networks (that is, work, family, and friends are independent groups), from which they are exposed to more varied subcultural models.⁵² This heteroglossia suggests that people internalize a variety of frames they encounter in their differing communities.⁵³ While these frames may be somewhat standardized—revealing the ways in which frames are a type of cultural knowledge distributed across members—the ways they are used in combination here are unique.⁵³

Our results demonstrating a diversity of frames used across health workers in a range of positions reveal a geography of deservingness that undocumented immigrants must face when seeking and receiving care at safety- net clinics. At each step of the process, from information-seeking to appointment scheduling, from clinical encounters to billing and follow-up, a patient may encounter a health worker who views them as either deserving of their time, attention, and care or not. If these encounters are underscored by health workers’ views of their patients as undeserving, then this may ultimately contribute to the “chilling effect” or “voluntary withdrawal”^(p.826) of undocumented immigrants from health care that they are eligible for, due to an internalized sense of undeservingness, and not necessarily explicit policies limiting access.²¹

While there are rules and regulations that health workers must follow, they are also the front-lines or “street-level” bureaucratic arms of the local government.⁷ As such, they have some discretion to interpret and enact government policies, even while being influenced by rules and bureaucratic processes.⁷ This research suggests that at safety- net clinics, even in places where frames of undeservingness are codified in state law, health workers view undocumented immigrants as deserving of health care, attention, and investment. Thus, these results reveal discrepancies between the views of deservingness in clinics and those expressed by state-level bureaucrats.

There are several limitations to this study. First, the sample size was small (n=31) and we used snowball sampling, which may have overestimated the similarity of frames. According to Goffman, impression management is a second limitation.⁵⁴ Individuals present themselves with certain fronts during performances, such as interview encounters, shaped by audiences and environments.^(p.17) These fronts are based more on desired impressions consistent with “characteristics that are socially sanctioned”^(p.67) than on the actual behavior of the unobserved individual. However, conflicted responses suggest that for many health workers, impression management was not the primary task. Third, the research leaves unanswered the question of how frames relate to behavior. Future research in this area might triangulate interview responses with observational data to connect the dots between impression management and actual behavior. Lastly, this research relies on interviews at two clinics at one end of the health care spectrum. Both clinics have reputations for providing care to the medically underserved. As such, this research only goes so far in capturing the full spectrum of views of health workers in Alabama. In order to more fully capture the geography of deservingness in Alabama, future research is needed on the health deservingness of undocumented immigrants outside of safety- net clinics.

Conclusions.

These results demonstrate the ways that frames, as mental shortcuts, map across individuals working at two safety- net clinics. By arguing for the health deservingness of undocumented immigrants, health workers in this study aligned themselves against current political discourse and health policies that deny the biolegitimacy of undocumented immigrants.^20,55 In so doing, health workers challenge the “unspoken–nearly ubiquitous–assumption that unauthorized im/migrants can and should be categorically excluded from the moral community in which the rest of us live, work, and vote.”^24(p.347) Perhaps the efforts of front-line health care workers to circumnavigate policies unfriendly to immigrants will serve as a first step in reframing health as a human right in the US, so that all residents can access and receive needed care, rather than having their care constrained by a patchwork of programs and exemptions.