Immigrant access in the Affordable Care Act: legacies of the Confederacy

During its first five years, the Affordable Care Act (ACA) built upon previous categorical distinctions among immigrants to solidify some inequalities and partially redress others. To analyse these changes, we build upon Tilly's theory of durable inequalities by adding the concepts of redress and retrenchment, reflecting the dynamics of change among countervailing powers in a policy field. We employ this theoretical framework to investigate the ways the ACA has selectively reduced barriers for certain categories of immigrants, but not others. Some of these strategies date back to the ways the white power elite in Confederate states set out to regain control as Congress acted after 1865 to grant freed slaves full citizen's rights. These barriers became blueprints for political strategies to block or subvert federal reforms. Additionally, we describe the ACA effort to reduce the legacy of de facto barriers for immigrants. We also detail how the federalist nature of the Act continued to allow wide-ranging forms of retrenchment and redress at state and local levels. Through this theoretical and historical analysis, we show how the ACA sought to redress certain historical inequalities of immigrant health care access but also solidified others, particularly in the case of undocumented immigrants.