Over the past five years, the undocumented immigrant population in the United States has remained relatively stable at around 10.5 million, following the historical maximum of 12 million in 2008 (Batalova, Blizzard, and Bolter 2020). Previous research has shown that health and health care inequities in the United States are significantly associated with immigrant documentation status (Bustamante et al. 2012). In 2019, approximately 46% of undocumented immigrants lacked health insurance compared to 9% of US citizens (Bustamante et al. 2021). The lower health insurance coverage rates among undocumented immigrants have been linked to suboptimal access to and use of health care. Although federal legislation such as the Affordable Care Act (ACA) has expanded eligibility and improved health insurance coverage for legally authorized immigrants, it has largely excluded undocumented immigrants (Ortega et al. 2022). Consequently, undocumented immigrants continue to face the worst patterns of access to and use of health care, and exclusion from health care has adverse consequences on health outcomes (Ortega et al. 2018).

Immigrants living in the United States often face difficulties when accessing health care because of legal, cultural, language, and navigation challenges (Perreira and Pedroza 2019). For undocumented immigrants, these hurdles are further compounded by immigration enforcement actions and exclusionary policies. Thus the overall health and well-being of this population deteriorates, as they have limited options for reliable health care. Two recent books—Pathogenic Policing: Immigration Enforcement and Health in the US South by Nolan Kline and Separated by William D. Lopez—provide detailed accounts and in-depth analysis of how immigration enforcement discourages access to and use of health care in mixed-status families (i.e., those where at least one household member is undocumented) and how immigration enforcement can lead to negative health outcomes.

Kline focuses on the state of Georgia, one of the most populous states that has yet to expand Medicaid, to examine the health-related disparities and outcomes experienced by undocumented immigrants and individuals of mixed-status families. This book provides a comprehensive analysis of the historical and political background of immigration enforcement policies, which have become increasingly militarized and punitive since the establishment of the Department of Homeland Security after the events of September 11, 2001. Kline explores in detail how Georgia's state and local governments actively contribute to immigration enforcement, such as making it more difficult for undocumented immigrants to drive by denying them Georgia-issued driver's licenses. In addition, local police forces collaborate with federal immigration authorities through actions such as detaining potential undocumented immigrants while driving or turning them over to immigration authorities after police raids. One strength of this book is its perspective on the consequences of immigration enforcement policies for the health care system. In addition to examining the effects on immigrants and mixed-status families, Kline investigates how health care providers, hospitals, social workers, community and immigration advocates, and government administrators are affected by immigration enforcement policies. Kline discusses the effects of a restrictive immigration state law, HB87, by describing how it banned health care providers from using public funds to offer “nonemergency health service” to undocumented immigrants. Although the courts eventually rejected this restriction, HB87 also imposed extra scrutiny and delays in issuing medical licenses to both citizen and noncitizen health care providers, resulting in staff shortages and chilling effects among providers.

Kline also identifies significant weaknesses within the US health safety net, which has limited resources for addressing the health needs of undocumented immigrants, and which often becomes the provider of last resort when undocumented patients are transferred from better-resourced hospitals to safety net hospitals in what is commonly referred to as “patient dumping.” Interestingly, the book documents the emergence of a predominantly informal and unregulated “shadow medical system” that undocumented immigrants often rely on as their usual source of care.

Lopez's book examines the experiences of twenty-four individuals from mixed-status families following an immigration raid in a small town in Michigan. He describes in vivid detail the destabilizing and adverse effects of an immigration enforcement action on the health and well-being of these households for both those who were deported and those who stayed in the United States. Families suddenly confronted with the deportation of their main source of economic support often find themselves dealing with trauma; the risk of homelessness and food insecurity; the challenges of coping with anxiety, depression, and posttraumatic stress disorder after the deportation of their relatives; and difficulties keeping the family together. Lopez also documents how mixed-status families must navigate the militarized and often biased deportation system during these moments of crisis. An interesting perspective of this book is Lopez's personal experience of joining police and immigration enforcement teams during the raids. This firsthand experience offers Lopez a unique opportunity to document the perspectives and limitations faced by those involved in immigration enforcement actions.

Like Kline, Lopez uses an anthropological perspective in his analytical framework, focusing on communities, families, and individuals to investigate how prejudice and racism in the United States have shaped the aggressive and militarized nature of immigration enforcement. Both books share a common view of social determinants within and outside the health system that affect the health of undocumented immigrants and mixed-status families. They examine policies that negatively impact health outcomes both within the health system, such as the exclusion of undocumented immigrants from the ACA, and beyond the health system. For example, Lopez and Kline outline and analyze anti-immigrant policies proposed at the state and local level that aim to make it difficult for undocumented immigrants to open bank accounts, rent apartments, or sign utility contracts. Such actions are intended to create so much hardship for undocumented immigrants that they will repatriate voluntarily or move elsewhere. Kline and Lopez also document the substandard living conditions, dangerous jobs, income instability, discrimination, and marginalization that undocumented immigrants face. Consequently, the cumulative effect of these policies and socioeconomic factors affect the health and overall well-being of undocumented immigrants and mixed-status households and further discourage health care access and use. Both Kline and Lopez emphasize the importance of community and local organizations in supporting mixed-status families after the sudden deportation of a family member. However, Kline highlights the limitations faced by these organizations, including funding, fragmentation, and lack of coordination between social and health safety nets, which limit their reach and effectiveness. The authors issue a common call for advocacy and policy change through grassroots movements as an effective way of addressing inequities caused by anti-immigrant and exclusionary policies.

Both books provide comprehensive descriptions of how undocumented immigrants have become targets of anti-immigrant policies and regulations implemented by the federal, state, and local governments. Recent research examines the adverse effects of recent exclusionary immigration policies on health care access and participation in public programs such as Medicaid and the Supplemental Nutrition Assistance Program (SNAP). Examples include changes in 2019 to the “public charge” rule and the implementation of title 42, a public health policy used during the COVID-19 pandemic to restrict immigration (Bustamante et al. 2022; Nwadiuko and Bustamante 2022). In addition to exclusionary policies, anti-immigrant rhetoric has contributed to what is commonly known as the “chilling effects” experienced by undocumented immigrants and their families. Both books describe how these chilling effects act as deterrents to seeking health care, which results in negative health outcomes, including chronic and mental health conditions. However, Kline primarily focuses on the health-related consequences of immigration enforcement, studying access to health care, social services, and public services exclusions for undocumented immigrants. Notably, the chilling effects experienced by mixed-status families extend beyond immigrants themselves and affect their US-born children, who may avoid enrolling or discontinue their participation in public programs such as Medicaid and SNAP to avoid disclosing the legal status of their immigrant parents (Barofsky et al. 2020).

Deportations that accelerated under both the Obama and Trump administrations and have persisted under the Biden administration are part of a long-term trend that began in the 1990s (Sohn et al. 2023). However, the undocumented immigrant population has been in decline for almost a decade as a result of restrictive immigration policies and the voluntary repatriation of undocumented immigrants (Bustamante et al. 2021). A recent study examining return migration to Mexico found that approximately 61% of Mexican migrants who returned from the United States since 2009 did so voluntarily, citing family reunification as the primary motivation to return, while 14% of the total return migration was the result of deportation (Dominguez-Villegas and Bustamante 2021). Some of these voluntary returnees, however, were following family members who were previously deported to Mexico because they were unwilling to live separated from their families or they could not support the remaining family members and thus followed the deported family member to Mexico.

Deportations have far-reaching consequences, not only for those who are deported but also for the family members left behind, as deportees are often the primary source of economic support of mixed-status families. A strength of Lopez's book is his narrative of the traumatic and violent nature of immigration enforcement, including his examination of the individual, familial, and overall societal consequences. Lopez's book describes the sudden, arbitrary, and unexpected nature of the deportation process, which prevents deportees and mixed-status families from preparing for life after deportation. One of the families interviewed in Lopez's book was forced to relocate to Mexico following the sudden deportation of the main source of economic support. Lopez examines how destabilizing this process is for mixed-status families, who suddenly must uproot themselves to a new country. This process has adverse consequences for all family members, but it is particularly challenging for US-born children who must emigrate to a country they barely know. Notably, more than half a million US-citizen children now reside in Mexico because of voluntary family reunification after a family member's deportation (Borja et al. 2021). The circumstances faced by mixed-status families in Mexico are adverse, as returnees struggle to secure employment for financial support and face restrictions in terms of access to education, health care, and other public services. Deported undocumented immigrants and their families often find themselves ineligible for health benefits in Mexico because they spent their productive lives working in the United States and did not contribute to Mexico's public health insurance programs (Dominguez-Villegas and Bustamante 2021).

The demographic composition of the undocumented immigrant population is rapidly changing because this group is aging more rapidly than the US-born population as a result of the reduced inflow of young undocumented immigrants (Bustamante et al. 2021). Considering how contentious immigration policy is at the federal level, some state and local governments are better equipped to address this issue; however, they would need to take action to reduce health care disparities by providing aging undocumented adults with quality health care as they age—and this population is more costly to cover. Some state governments, such as California, Illinois, New York, and Washington, have taken steps to expand Medicaid eligibility for specific groups of undocumented immigrants (Bustamante, Nwadiuko, and Ortega 2022). However, as Kline and Lopez argue, access to federal programs, including Medicare and Medicaid, and broad immigration reform will become necessary measures in bridging the gaps within our current system.

Overall, both books contribute to our understanding of the far-reaching consequences of US immigration enforcement on various stakeholders, including undocumented immigrants, mixed-status families, immigrant communities, and health systems. Although each book has a distinct geographic and thematic perspective, both books analyze the inequities and disadvantages faced by undocumented immigrants and mixed-status families while advocating for system change. Pathogenic Policing, however, provides a more comprehensive analysis of the effects of immigration enforcement on health care providers and systems, and it explores the broader issues of health inequities perpetuated by these polices. By contrast, Separated offers a more focused examination of the experiences of undocumented immigrants and mixed-status families affected by a single immigration raid, and it investigates the social and emotional consequences of deportation. Both books conclude by highlighting the need for closing coverage gaps and the disadvantages experienced by undocumented immigrants and their families, advocating for grassroots activism and social change.

References

Barofsky, Jeremy, Vargas, Ariadna, Rodriguez, Dinardo, and Barrows, Anthony.
2020
. “
Spreading Fear: The Announcement of the Public Charge Rule Reduced Enrollment in Child Safety-Net Programs
.”
Health Affairs
39
, no.
10
:
1752
61
. https://doi.org/10.1377/hlthaff.2020.00763.
Batalova, Jeanne, Blizzard, Rittany, and Bolter, Jessica.
2020
.
Frequently Requested Statistics on Immigrants and Immigration in the United States.
Washington, DC
:
Migration Policy Institute
.
Borja, Sharon, Cardoso, Jodi Berger, Cruz, Pedro Isnardo De La, Perreira, Krista M., Giraldo-Santiago, Natalia, and Jasso Oyervides, Martha Virginia.
2021
. “
Health Insurance Access among US Citizen Children in Mexico: National and Transborder Policy Implications
.”
Health Affairs
40
, no.
7
:
1066
74
. https://doi.org/10.1377/hlthaff.2021.00087.
Bustamante, Arturo Vargas, Beltrán, Lucía Félix, Nwadiuko, Joseph, and Ortega, Alexander N..
2022
. “
Avoiding Medicaid Enrollment after the Reversal of the Changes in the Public Charge Rule among Latino and Asian Immigrants
.”
Health Services Research
57
, suppl. 2:
195
203
. https://doi.org/10.1111/1475-6773.14020.
Bustamante, Arturo Vargas, Chen, Jie, Beltrán, Lucía Félix, and Ortega, Alexander N..
2021
. “
Health Policy Challenges Posed by Shifting Demographics and Health Trends among Immigrants to the United States
.”
Health Affairs
40
, no.
7
:
1028
137
. https://doi.org/10.1377/hlthaff.2021.00037.
Bustamante, Arturo Vargas, Fang, Hai, Garza, Jeremiah, Carter-Pokras, Olivia, Wallace, Steven P., Rizzo, John A., and Ortega, Alexander N..
2012
. “
Variations in Healthcare Access and Utilization among Mexican Immigrants: The Role of Documentation Status
.”
Journal of Immigrant and Minority Health
14
, no.
1
:
146
55
. https://doi.org/10.1007/s10903-010-9406-9.
Bustamante, Arturo Vargas, Nwadiuko, Joseph, and Ortega, Alexander N..
2022
. “
State-Level Legislation during the COVID-19 Pandemic to Offset the Exclusion of Undocumented Immigrants from Federal Relief Efforts
.”
American Journal of Public Health
112
, no.
12
:
1729
31
. https://doi.org/10.2105/AJPH.2022.307130.
Dominguez-Villegas, Rodrigo, and Bustamante, Arturo Vargas.
2021
. “
Health Insurance Coverage in Mexico among Return Migrants: Differences between Voluntary Return Migrants and Deportees
.”
Health Affairs
40
, no.
7
:
1047
55
. https://doi.org/10.1377/hlthaff.2021.00051.
Nwadiuko, Joseph, and Bustamante, Arturo Vargas.
2022. “Little to No Correlation Found between Immigrant Entry and COVID-19 Infection Rates in the United States.”
Health Affairs (Millwood)
41
, no.
11
:
1635
44
. https://doi.org/10.1377/hlthaff.2021.01955.
Ortega, Alexander N., Chen, Jie, Roby, Dylan H., Mortensen, Karoline, Rivera-Gonzalez, Alexandra C., and Bustamante, Arturo Vargas.
2022
. “
Changes in Coverage and Cost-Related Delays in Care for Latino Individuals after Elimination of the Affordable Care Act's Individual Mandate
.”
JAMA Network Open
5
, no.
3
: article ID e221476. https://doi.org/10.1001/jamanetworkopen.2022.1476.
Ortega, Alexander N., McKenna, Ryan M., Pintor, Jessie Kemmick, Langellier, Brent A., Roby, Dylan H., Pourat, Nadereh, Bustamante, Arturo Vargas, and Wallace, Steven P..
2018
. “
Health Care Access and Physical and Behavioral Health among Undocumented Latinos in California
.”
Medical Care
56
, no.
11
:
919
26
. https://doi.org/10.1097/MLR.0000000000000985.
Perreira, Krista M., and Pedroza, Juan M.
2019
. “
Policies of Exclusion: Implications for the Health of Immigrants and Their Children
.”
Annual Review of Public Health
40
: 147–66. https://doi.org/10.1146/annurev-publhealth-040218-044115.
Sohn, Heeju, Pebley, Anne R., Gonzalez, Amanda Landrian, and Goldman, Noreen.
2023
. “
Deportations and Departures: Undocumented Mexican Immigrants’ Return Migration during Three Presidential Administrations
.”
PNAS
120
, no.
9
: article ID e2212184120. https://doi.org/10.1073/pnas.2212184120.