Impact of Alabama’s Immigration Law on Access to Health Care Among Latina Immigrants and Children: Implications for National Reform

Abstract

We conducted in-depth interviews in May to July 2012 to evaluate the effect of Alabama’s 2011 omnibus immigration law on Latina immigrants and their US- and foreign-born children’s access to and use of health services.

The predominant effect of the law on access was a reduction in service availability. Affordability and acceptability of care were adversely affected because of economic insecurity and women’s increased sense of discrimination. Nonpregnant women and foreign-born children experienced the greatest barriers, but pregnant women and mothers of US-born children also had concerns about accessing care.

The implications of restricting access to health services and the potential impact this has on public health should be considered in local and national immigration reform discussions.

IN THE ABSENCE OF RECENT national immigration reform, state legislatures have increasingly proposed measures to address local immigration issues. Since 2007, legislators have put forth more than 1300 immigration-related bills and resolutions annually.¹ Most of these failed to become law; however, in the past 4 years, Alabama, Arizona, Georgia, Indiana, South Carolina, and Utah have passed omnibus legislation to enforce immigration policy and discourage settlement of unauthorized immigrants.¹ These laws contain numerous provisions that authorize local law enforcement personnel, employers, and others to verify an individual’s immigration status. All of these states also require verification of lawful presence in the United States for individuals seeking public benefits, such as health care, from state and local agencies; exceptions are made for prenatal and emergency care, child and adult protective services, and other services exempt under federal law (e.g., immunizations; the Special Supplemental Nutrition Program for Women, Infants, and Children; and short-term in-kind disaster relief).²

Previous research has found that laws aimed exclusively at restricting immigrants’ access to public benefits reduce immigrants’ use of health services. Following the 1994 passage of California’s Proposition 187, immigrants failed to receive or delayed medical care out of fear of deportation.^3,4 As reported in one study, fear of deportation that results in delayed treatment of communicable diseases, such as tuberculosis, can pose significant health risks to the individual and the general public.³ Requirements to present proof of lawful residence to receive publicly funded health services, such as those established in the 2005 Deficit Reduction Act, can also affect eligible legal residents and US citizens,^5–7 and groups that are less able to provide appropriate documentation, such as adolescents and the elderly, may be deemed ineligible for services.^6,8

The broader scope of recent state-level initiatives means that immigrants’ use of health care may be adversely affected not only because unauthorized immigrants are explicitly prohibited from receiving services, but also because the laws may exacerbate transportation and financial barriers, which affect other aspects of health care access. Anecdotal evidence suggests that recent state legislation has indeed hindered immigrants’ access to routine health care.^9,10 However, few studies have assessed how these laws have affected immigrants’ use of health services.^11,12 With growing calls for comprehensive national immigration reform, it is important to evaluate the impact of state-level laws on immigrants’ access to care to inform discussions that will shape future policies.

We examined Latina immigrants’ experiences accessing health care following the June 2011 passage of the Alabama Taxpayer and Citizen Protection Act, House Bill 56 (HB 56), which was considered the toughest state immigration law in the United States.¹³ Specifically, we assessed the range of ways the law has affected several dimensions of access to care for Latina immigrants and their US- and foreign-born children. Latino immigrants constitute the largest immigrant group in Alabama and in the United States overall^14,15; in fact, Alabama reported the second-largest percentage increase in its Latino population between 2000 and 2010, after South Carolina.¹⁶ We focused on Latinas because they have a primary role in their children’s health and health care and typically have more health needs and greater use of health services than men.^17,18

CONCEPTUAL FRAMEWORK

To evaluate how omnibus immigration legislation affects access to care, it is useful to conceptualize access as having multiple dimensions that influence a person’s use of health services: availability (an adequate supply of the types of services that clients need), affordability (clients’ ability to pay for services), accommodation (sufficient flexibility of services to meet clients’ needs), acceptability (clients’ comfort with health care sources and providers), and accessibility (clients’ ability to reach sources of care).¹⁹

Alabama’s HB 56 may affect Latino immigrants’ access to care across several of these dimensions. For example, the law requires verification of lawful US residence from persons seeking public benefits from state and local agencies, although exceptions are granted for select public health services, such as immunizations; testing and treatment of symptoms of communicable diseases; prenatal care; coupons for the Women, Infants, and Children's nutrition program; and treatment of emergency medical conditions. This may directly affect availability, because unauthorized immigrants are no longer eligible for many subsidized services at publicly funded agencies, where they typically received care.^20,21 Moreover, Latinos may be reluctant to seek care because exemptions under the law are not well known, and they may believe they are ineligible for services of any kind at public clinics and hospitals.

In addition, provisions authorizing local law enforcement to verify the legal residence of anyone they lawfully stop and suspect may be in the country without authorization may affect accessibility, because immigrants limit their mobility out of fear of being stopped while driving.^11,22 The law also may affect affordability, because new documentation requirements and other employment-related provisions restrict immigrants’ job opportunities and create financial insecurity. Finally, the law may adversely affect acceptability by heightening immigrants’ perceptions of marginalization and discrimination by clinic staff or by creating fear that health care providers will report them to authorities.^22–24

METHODS

To examine how Alabama HB 56 has affected these dimensions of access, we conducted in-depth interviews with Latina immigrants of childbearing age residing in Jefferson County, Alabama, which hosts the state’s largest population of Latino immigrants.²⁵ The main sources of primary and preventive health care for Latino immigrants in Jefferson County prior to HB 56 were the county health department, which is supported by a combination of federal, state, and local funds, and federally qualified health centers. Limited preventive and specialty care (e.g., dental cleaning) was also available at small nonprofit and faith-based organizations. The county hospital and a university hospital have served as the main centers for advanced health care services, including pregnancy-related care, which uninsured, unauthorized pregnant immigrants pay for out of pocket at a reduced fee, because Alabama does not cover prenatal care for this population through the Children’s Health Insurance Program. US citizens and eligible legal residents can obtain free or low-cost services through Medicaid or Medicaid expansion programs (e.g., the children's insurance program) at the same county and university hospitals; the 2011 legislation did not affect Medicaid eligibility.

Latinas were eligible for our study if they were aged 19 to 49 years, had children younger than 18 years, resided in Jefferson County, and were living in Alabama when HB 56 was passed (although being born outside the United States was not an eligibility requirement, all of our participants were immigrants). To reduce mistrust and thereby increase participation rates, we used snowball sampling to identify eligible women. We also hired native Spanish-speaking Latina interviewers who had developed trusted relationships in the Latino immigrant community through previous community-based participatory research initiatives.^26,27 The interviewers’ existing contacts referred other women they knew, whom the interviewers then screened for eligibility and interest in the study. Only 2 women who were screened declined to participate.

We recruited 30 participants by theoretical sampling,²⁸ in which we selected participants according to characteristics that were most likely to influence health care access. The main characteristic we theorized would affect children’s access to health care was their country of birth (United States or a foreign country), because this largely determines their eligibility for publicly funded health coverage, such as Medicaid; we sought a balanced sample of women who had only US-born children or at least 1 foreign-born child. We theorized that for women, a recent history of pregnancy would be the most influential characteristic affecting their own use of health services, because the majority of women in this population are of reproductive age,²⁹ and prenatal care is exempt from the law’s documentation requirements, which may facilitate health care access. Women were eligible for this subsample if they were pregnant or had delivered a child within 6 months prior to the interview, because they would have spent all or much of their pregnancy in the period following the law's enactment. Throughout recruitment, we reviewed the progress of sampling to ensure that women were included in each of the cells in our sample design. After 10 interviews with pregnant women, we had reached thematic saturation and recruited nonpregnant women for the remaining participants. Our final sample comprised 15 women with US-born children (9 nonpregnant and 6 pregnant women) and 15 women with at least 1 foreign-born child (11 nonpregnant and 4 pregnant women).

Interviews

The in-depth interviews took place between May and July 2012. We interviewed women in their homes or another place of their choosing. We conducted all interviews in Spanish and recorded them with participants’ permission. At the beginning of the interview, we asked women a series of sociodemographic questions; participant characteristics are presented in Table 1.

TABLE 1—

Characteristics of Latina Immigrants Participating in Study of Effects of State Immigration Law on Health Care Access: Alabama, 2012

Characteristics	No. (%)
Country of origin
Mexico	24 (80)
Other foreign country	6 (20)
Duration of residence in Alabama, y
< 5	5 (7)
5–9	15 (50)
≥ 10	10 (43)
Educational attainment
< high school	21 (70)
≥ high school	9 (30)
English language proficiency
None, does not speak well	15 (50)
Average	14 (47)
Very good	1 (3)
Employment
Employed	13 (43)
Not employed	17 (57)
No health insurance	29 (97)
Regular source of health care	23 (77)

Note. The sample size was n = 30; median age = 32 years.

The in-depth interview guide included sections on participants' knowledge of HB 56, changes they had observed in their families and communities since the law was passed, and experiences accessing health care for themselves and their children before and after passage of HB 56. We based questions about participants’ experiences obtaining care on our conceptual framework on the dimensions of access and on previous research identifying barriers to care among Alabama’s Latino immigrant population.^23,24 We did not include any questions in the interview guide that specifically asked women about their own or their children's legal status, to promote trust between participants and interviewers; however, some women volunteered this information. The interviews lasted an average of 40 minutes.

Before the interview, participants provided written consent. They received $20 for their participation.

Data Management and Analysis

We transcribed recordings of the interviews in Spanish. We then reviewed the transcripts for accuracy against the recordings and corrected any errors and omissions. We used NVivo 10 (QSR International, Doncaster, Victoria, Australia) to manage and code the transcript data.

We used constant comparison and content analysis to code and analyze the transcripts.³⁰ K. W. and a qualitative research assistant independently coded 5 transcripts; we derived codes from the research questions, barriers to access reported in the literature, and emerging themes in the data. In meetings that followed the reading of each transcript, we reviewed our consistency in coding, discussed discrepancies, and assigned codes to text once we reached consensus. At this point, we had solidified our intercoding reliability and finalized the coding scheme. Then, we divided the remaining transcripts into 2 groups, which we each coded exclusively; met to discuss any passages about which we were unsure of the most appropriate code; and reviewed select transcript segments to ensure consistency in coding.

In the second stage of analysis, we categorized the main themes in participants’ responses about changes in health-seeking behavior and experiences getting care since HB 56 was passed, according to the dimensions of health care access in our conceptual framework. We combined the dimensions of accommodation and acceptability, because several themes in women’s responses overlapped with these concepts. We also compared these themes across subgroups by women’s pregnancy status and children’s country of birth; we did not identify differences between our sampling cells (e.g., nonpregnant women with foreign-born vs US-born children) and therefore described differences across the 2 subgroups only.

RESULTS

Women discussed a variety of ways Alabama’s immigration law affected their experiences seeking care for themselves and their children. Table 2 provides an overview of the main themes about how the law affected the different dimensions of health care access and summarizes differences across subgroups.

TABLE 2—

Effects of State Immigration Law on Health Care Access for Latina Immigrants and Their Children: Alabama, 2012

Area of Concern	Representative Participant Quotation	Differences by Children's Country of Origin and Mothers' Pregnancy Status
Availability
Perceived ineligibility for publicly funded health services	Before, you could go [to the public clinic] without insurance. If you worked, you just showed how much you earned. It’s not like that now. Now they just see people who have health insurance [or] who are here legally.	Child’s country of origin: more women with foreign-born than US-born children discussed their child being ineligible for services.
		Pregnancy status: few observed differences.
Denial of services because of new citizenship requirements	The last time I went to WIC, the woman started asking me for insurance and all this paperwork… . I told her, “But it’s already here, entered. I bring that every year, not every six months, and now I just want to pick up my coupons” and … she didn’t want to give them to me.	Child’s country of origin: denial of services was only reported by women seeking care for their foreign-born child.
		Pregnancy status: nonpregnant women were more likely to report being denied care, even when they presented for exempt services.
Uncertainty about obtaining future care	[If] the clinic I go to closes … and I have to go some other place, I … would be afraid about whether they were going to see me.	Child’s country of origin: women with foreign-born children were more likely to express uncertainty about their child getting care in the future, although some women with US-born children also feared their child’s benefits would be taken away.
		Pregnancy status: few observed differences.
Affordability
Concern over future cost of care	If you needed an operation, I don’t know if they would give you a loan, that the hospitals would give you credit. Maybe they couldn’t give it to you simply because you don’t have papers.	Child’s country of origin: women with foreign-born children were more likely than women with US-born children to be concerned about ability to pay for their child’s care.
		Pregnancy status: few observed differences.
Higher charges for health care	After the law they charged me more, they charged me almost $70, and [before the law I paid] $35.	Child’s country of origin: higher cost of care was only reported by women seeking services for their foreign-born child.
		Pregnancy status: higher cost of care was only reported by nonpregnant women.
Accommodation and acceptability
Mistreatment by staff at clinics and hospitals	Because they see that we’re Hispanics and they make an ugly face. They no longer take care of us like before.	Child’s country of origin: few observed differences.
		Pregnancy status: few observed differences.
Concern and confusion about new documentation requirements	When they told me that I had to fill out the immigration paper, I said, “But why if the one who is going to get the service is her [my daughter], not me?”	Child’s country of origin: women with US-born children were more likely to be frustrated about new documentation requests, because their child had greater contact with the health system after the law was enacted.
		Pregnancy status: few pregnant women expressed concerns with new documentation requirements because prenatal care is exempt under the law.
Fear of deportation at sources of care	Because you run the risk that you go [to the clinic] sick and they say, “Here is ICE, they’re already here for you.” Even outside the clinic.	Child’s country of origin: few observed differences.
		Pregnancy status: nonpregnant women were more likely to be concerned about being deported for seeking care.
Accessibility
Fear of driving	You have to take them… . [You are afraid] that they’re [the police] going to stop you. Driving is not the same as before.	Child’s country of origin: few observed differences.
		Pregnancy status: few observed differences.

Note. ICE = Immigration and Customs Enforcement; WIC = Special Supplemental Nutrition Program for Women, Infants, and Children.

Availability

The most common themes that emerged in women’s responses related to the availability of health care services (Table 2). Many participants stated that they were afraid that local clinics and hospitals would no longer see them or their foreign-born children if they presented for care. Often these fears originated from stories or rumors they had heard in their community; very few women expressed accurate knowledge of the law’s specific provisions relating to health care and knew which services were exempt. Because participants did not believe they were eligible for any services, some reported that they had not sought care for themselves or their foreign-born children since the law was passed, despite needing a well-child visit or having a cold, the flu, or chronic back or kidney pain. Perceived ineligibility for care prompted concern among those with underlying health problems, as noted by a Honduran woman with foreign-born children: “You don’t know what’s going on in your body, if it’s really serious, and … you can no longer go [to the doctor].” Several interviewees commented that they were using home remedies or trying to treat their conditions with over-the-counter medications in lieu of seeking care in the formal health sector. Although all 10 pregnant women eventually received prenatal care, a few said they initially delayed seeking care after realizing they were pregnant because they were afraid they would not be seen.

New citizenship requirements and exemptions also affected availability of care, especially for nonpregnant women and foreign-born children. Participants recounted experiences in which administrative staff at local clinics seemed unaware of health service exemptions under the law and asked women to provide additional documentation before receiving coupons for the Women, Infants, and Children's nutrition program, testing for flu, prenatal care, and Papanicolaou tests covered under Title X. In some instances, women and their foreign-born children were initially denied care but later seen, as in the cases of an undocumented Mexican child making a visit for flu and a Salvadoran child with legal residency needing a well-child checkup; only after making numerous calls did registration staff determine that the children were eligible, and they were eventually seen. However, in other cases participants who were turned away had been unable to obtain services elsewhere. Although most women and children who were denied care presented for exempt services, a couple of interviewees reported being told that their daughters could not be seen because they were not born in the United States and were seeking care for nonexempt medical reasons.

In addition, participants were uncertain about whether they would be able to continue receiving medical attention at their usual sources of care in light of their documentation status, even if they had obtained care following the law. Overall, mothers with US-born children were less concerned about their child’s current and future eligibility for care because they “have their social [security number and] have their Medicaid.” However, some interviewees with US-born children said they were worried that their child would be denied care because of their own legal status. A few also said they had heard that benefits for US-born children, such as Medicaid, might be taken away or that they would not be given birth certificates, thereby preventing them from obtaining medical care in the future.

Affordability

The second most common themes related to affordability. Many participants said they worried about being able to afford health care. Both nonpregnant and pregnant women and several mothers of foreign-born children expressed concerns about future costs of care, but women with US-born children rarely mentioned this. Because many interviewees did not believe that they would be eligible for services at public clinics and hospitals, they were concerned that they would be forced to seek services in the private sector, where “everything is really expensive.” In addition, participants feared that they would no longer be able to make payment arrangements for large bills should major medical conditions arise or current health problems get worse. As illustrated by a Mexican mother of 4 who had been unable to follow up on abnormal blood results, this also raised concerns about caring for their family:

What I want more than anything … is that my expenses are covered so that I can find out what it is, what they can do for me … because I have my little ones, and, think about it, if something worse were to happen, that keeps me in bed, what about my kids?

Financial insecurity after enactment of the law also increased interviewees’ fears about being able to afford care. As a pregnant Mexican-born mother of 3 noted, often this was because regular work was more difficult to find, “Not every place is hiring because [you need] documents. So if you don’t have money, you don’t have a way to buy medicine, you don’t have a way to go to the doctor.” Economic instability also caused a few interviewees to delay care or not seek services, as illustrated by a Mexican participant who had difficulty finding work after the law went into effect and did not attend her follow-up appointment for a miscarriage:

They told me that I had to come back for another appointment … but the truth is, the day that I had the appointment, I didn’t have any money and if I don’t pay, they are not going to see me.

Several participants said they had heard that clinics were charging more for services in the initial period following passage of the law, and a few stated that they had directly experienced increased costs for care. They reported substantially higher costs or being asked to pay for previously free services, such as Papanicolaou tests and sick visits. Such incidents were primarily mentioned by nonpregnant women; none of the women with US-born children cited problems with changing costs of care after the law was passed.

Accommodation and Acceptability

Many participants described experiences of mistreatment by staff at local clinics, which affected their perceptions of local clinics’ abilities to meet their needs and the acceptability of these sources of care. Reports of mistreatment were common among women seeking care for both US- and foreign-born children, as well as for pregnancy and other medical reasons. Many participants described mistreatment by registration and billing staff, although a few cited mistreatment by clinical staff as well. They reported a noticeable, negative difference in how they were treated once the law was passed. One interviewee said, “[As soon as] they see that you’re Hispanic … you can see them change.”

Many interviewees stated that they were treated in a discriminatory manner, and staff often made it difficult for them to conduct routine clinic business, such as scheduling appointments or applying for programs, as noted by a Honduran mother trying to make an appointment for her US-born son who had an earache:

They told me, “If it’s not an emergency, don’t bring him.” Before they made the appointment, “He has an ear ache? Okay.” … You call the same day to make the appointment. I think [the change] has to be because of the law. The child [is] no longer the most important.

Several participants stated that because of such poor treatment by clinic staff, they no longer wanted to obtain care at the clinics they had regularly attended.

New procedures for checking citizenship and residency status when registering for visits further contributed to perceptions of discrimination, particularly among interviewees with US-born children. Although a few said that registration staff simply asked if they or their children were born in the United States or were legal residents, most reported that they were asked to sign a written declaration stating the patient was a citizen or legal resident to receive services. Participants with US-born children commented that they were able to comply with the requirements, but even when they understood they were being asked about their child’s citizenship, many were upset and felt they were being discriminated against because they were Latina or presumed to be undocumented.

Several other interviewees believed they were being asked about their own legal status even though their child was the one receiving care. As described by a Mexican immigrant with US-born children, such requests created uncertainty and mistrust surrounding the clinical encounter:

Because before [the law] they hadn’t asked me, and they were doing this since the law was passed. I was afraid that one day they were going to check on you, that they were going to tell the police that you are here.

A related theme, which emerged somewhat less frequently, was that participants were afraid that clinic staff would report them to the police or Immigration and Customs Enforcement or that law enforcement waited outside of clinics to apprehend undocumented clients. Interviewees discussed this primarily in the context of their own use of care, rather than that of their children, and few pregnant women mentioned this as a concern. Although only 1 participant reported not seeking care specifically for this reason, others were nervous or uncertain about whether they would be turned over to authorities were they to seek care and were worried about what would happen to their families, as a participant from Mexico who had US-born children explained, “I always take my kids to the doctor with me, and if they called the police and picked me up, where are my kids going to go?”

Accessibility

The majority of participants reported that following passage of the law, they limited their driving to essential errands and transportation to work to minimize their risk of being stopped by police and possibly detained. Participants’ stories about how their friends, their relatives, and even their husbands had been stopped while driving and were facing deportation demonstrated that such a risk was very real. However, fear of driving kept only a few from seeking health care for themselves and occasionally for their children. Although fear of driving did not frequently prevent participants from obtaining services, it remained a concern for women in all subgroups who continued to make medical visits, as highlighted by the following statements:

When I started going to my [prenatal care] appointments, I was worried, and said to myself … “only God knows if I am going to return home or not.” There in the hospital, too, I heard stories and people told me, “They picked up my friend” or “my brother-in-law” and things like that. It was a very tense time (postpartum Mexican woman).

Their health comes first. I take them, risking that the police might stop me (Mexican woman with US-born children).

DISCUSSION

Our results indicate that Alabama’s omnibus immigration law, HB 56, has adversely affected access to care for Latina immigrants and their children across multiple dimensions. This is attributable to provisions directly addressing immigrants’ eligibility for public benefits, as well as other components and unintended consequences of the law, such as mistreatment by clinic staff. We also found that pregnant and nonpregnant women and mothers of US- and foreign-born children shared several similar concerns and experiences accessing care. These findings provide additional evidence of the detrimental effects that increased local immigration enforcement has had on immigrant health and use of medical services noted in other studies.^11,22

Perhaps not surprisingly, in light of the explicit restrictions in the law regarding receipt of publicly funded health services, the most frequent themes that emerged related to the availability of care. Not only were many women and their foreign-born children no longer eligible for many services at public clinics, but lack of awareness of health service exemptions among Latina immigrants and clinic staff resulted in failures to seek or receive care. Moreover, in a context of heightened fears, women may believe they have even fewer options for care as a result of community rumors surrounding eligibility for services. Although there is clearly a need to provide more accurate information to the Latino community and health care staff about HB 56, educational initiatives alone will not reduce other barriers to care (e.g., affordability) that have resulted from different provisions of the law.

Although our participants also reported fear of driving and fear of deportation resulting from seeking care at clinics, these were not commonly cited barriers to access, as has been reported elsewhere.^11,22 Rather, the other main law-related barriers we identified were economic insecurity stemming from new sanctions surrounding employment, which affected affordability, and interviewees' increased sense of discrimination and mistrust, which influenced perceptions about accommodation and acceptability of health care sources. Although a recent study did not find a significant association between employment verification systems (i.e., E-verify) and unauthorized Mexican migrants’ access to health care,¹² in the Alabama context, this mandate occurred along with other restrictions that left immigrants with few publicly subsidized health care options and more limited financial resources to pay the full cost of care in the private sector. It is difficult to know whether participants’ perceived mistreatment was the result of discriminatory behavior on the part of staff or a greater sense of marginalization following enactment of the law that colored women's perceptions of routine encounters. Observational data and an assessment of staff attitudes would provide important information about discrimination in this service environment, but it is clear that women’s perceptions, combined with barriers in other dimensions, have reduced access to care for many Latinas we interviewed, along with their children.

Our findings also indicate that although HB 56 affected some groups differently, Latinas and children across a range of legal statuses and eligibility for care have been affected by the law. Interviewees who were not pregnant and foreign-born children more frequently experienced obstacles that prevented them from obtaining care when needed, likely because they are not eligible for Medicaid and many health services for these groups are not exempt under the law. However, participants with US-born children and pregnant women also experienced changes in accessing care. For example, several participants with US-born children were confused over new documentation requirements and expressed uncertainty about whether their child would remain eligible for services, concerns that other studies suggest lead to lower utilization of care.^5,6 In addition, interviewees in all groups reported incidents of being mistreated by clinic staff that they attributed to the law.

The impact of state immigration laws on health care access creates several new challenges to addressing the health needs of Latino immigrants. Prior to passage of these laws, Latino immigrants, and unauthorized immigrants in particular, faced a variety of barriers to care, such as lack of health insurance, transportation, and English proficiency.^23,24,31,32 The narratives of our interviewees, as well as findings from other studies,^11,22 suggest that recent local immigration legislation has exacerbated these barriers.

Furthermore, by reducing immigrants’ access to health care, these laws could increase health disparities in this population, especially because options for health care for unauthorized and recent immigrants are diminishing. Under the Affordable Care Act, these groups are prohibited from receiving tax credits to buy health insurance and from participating in state health insurance exchanges, while remaining ineligible for Medicaid. Although locally funded programs are a possible pathway to provide coverage to this population,³³ this is unlikely in states that have passed laws restricting immigrants’ access to public benefits. A remaining option is the private sector^33,34; however, as many of our interviewees reported, this is not a realistic alternative because of the higher costs of care in private settings and the greater financial insecurity they face.

It is also important to note that the impact of these provisions on health and well-being extends beyond the unauthorized immigrants targeted by the legislation.¹¹ Many Latino immigrants live in mixed-status households containing both unauthorized immigrants and US citizens.³⁵ Existing gaps in access to health care between family members because of their legal status are likely widened by these laws. This may compromise the health of those with more restricted access to care, which in turn affects the larger family unit—a concern expressed by several of our interviewees. Failure to appropriately diagnose and treat medical conditions because of immigrants’ inability or reluctance to access care or clinic staff’s lack of awareness of health service exemptions has public health implications both within and outside the Latino community. Risk of communicable diseases such as influenza and tuberculosis may rise if immigrants do not get vaccinated or delay early treatment.^3,36 Furthermore, communities may see additional economic costs if severe complications from chronic conditions are addressed through emergency services rather than timely primary care.^18,37

Limitations

We conducted a small qualitative study of Latina mothers of childbearing age residing in the Birmingham metropolitan area, and their experiences may not reflect those of Latino immigrants who are older, male, living in more rural areas where access to care is more limited, or living in states with different provisions in local immigration laws. However, this was one of the few recent in-depth studies of a state-level immigration law’s impact on immigrants’ access to care and points to important ways that large-scale legislation may affect different dimensions of health care access. Although snowball sampling was the most feasible approach for recruiting participants in this social climate, it likely contributed to the fact that few of our participants were recent immigrants and none were US-born Latinas, whose experiences accessing care are expected to differ because of their relative familiarity with local health systems and eligibility for services.

Finally, we do not know the extent to which Latino immigrants in this community have reduced their use of publicly funded health services and the impact this has on health outcomes. Studies of laws with similar components indicate that service utilization declines,^5,6,11 and our participants’ stories suggest that immigrants have indeed changed their health-seeking behavior. However, additional research is needed to document any larger changes that have taken place in settings with omnibus legislation, and we plan to examine some of these issues in future analyses.

Conclusions

Our findings indicate that state-level immigration laws that primarily focus on deterring the settlement of unauthorized immigrants adversely affect health care access and have consequences beyond those originally intended. As immigration reform returns to the national agenda, border enforcement and public safety will remain central components of the policy discussions. However, these conversations should also consider lessons that can be learned from state-level immigration initiatives, such as the implications of not providing new immigrants and those on a path to citizenship with access to publicly funded health services and the potential impact this would have on broader public health.