The Documentation Status Continuum and the Impact of Categories on Healthcare Stratification

Abstract

Public discourse on immigration and social services access has been contentious in immigrant-receiving countries. Scholars have examined immigrants’ marginalization as a form of civic stratification, where boundaries based on documentation status affect immigrants’ experiences and benefits granted by the state. This scholarship lacks a framework outlining existing documentation status categories and does not fully answer three research questions I pose in this article: (1) what is the alignment of documentation status categories relative to each other, (2) how does policy (re)configure those categories over time, and (3) how have documentation status categories shaped access to health care in the United States? This article answers those questions and argues that the documentation status continuum (DSC) framework fills these gaps. In the DSC, undocumented immigrants are at one end and citizens are at the other, with many documentation statuses in between. Public policy creates these statuses and generates stratification through allocating benefits based on one’s DSC position. Policy also shapes movement along the continuum, which shapes benefits eligibility. Using the 2006 Massachusetts Health Reform and national 2010 Affordable Care Act (ACA) Reform as policy examples and interviews conducted with 207 immigrants, healthcare professionals, and immigrant organization employees in Boston, this article demonstrates how healthcare access is stratified along the DSC between citizens and noncitizens. This has implications for various outcomes that social scientists examine amid increasing anti-immigrant sentiment in the US and beyond.

1. Introduction

Recent discourse on immigration and access to public benefits has been contentious. This discourse is part of an intensifying anti-immigrant socio-political climate in the US and other Global North immigrant-receiving countries (Benson and Lewis 2019; Joseph 2020; Sadeghi 2019; Tarabusi 2019). While past scholarship framed documentation status as a binary with undocumented immigrants on one side and documented immigrants on the other, scholars are increasingly examining “gray area” documentation statuses between undocumented and citizenship status (Bialas et al. 2024; Menjívar 2006, 2023, 2024; Torres and Waldinger 2015; Van Natta et al. 2019).1 In the United States, immigrants with some legal protection face precarity exacerbated by their noncitizen status. Their “liminal legality” does not prevent detention or deportation if they fall out of status (Kominers 2016; Menjívar 2006, 2023). Thus, all noncitizens are deportable and not entitled to the same protections as citizens (Cohen 2015; Golash-Boza 2015).2 This body of research emphasizes the growing importance of state-created categories and classification systems that shape migrants’ access to various resources (Bialas et al. 2024; Fox 2016; Menjívar 2023; Tuohy 2020; Van Natta et al. 2019). More directly, Menjívar (2023) argues that though these categories indelibly shape people’s lived experiences, they are often shrouded from visibility, making it difficult to recognize their impact. However, the marginalization that immigrants experience because of these categories represents what scholars refer to as “civic stratification,” where boundaries are drawn between noncitizens and citizens, affecting the rights granted to them by the state (Lockwood 1996; Massey 2017; Morris 2003; Torres and Waldinger 2015; Wimmer 2013).

This article aims to answer Menjívar’s (2023) call by making these documentation status categories more visible through explicitly delineating them. More specifically, this article addresses three important research questions that existing immigration and boundaries scholarship have not fully answered: (1) what is the alignment of documentation status categories relative to each other, (2) how does policy (re)configure those categories over time, and (3) how have documentation status categories shaped access to health care under in the United States? I answer these questions and show that there are a range of categories that exist along what I call a documentation status continuum (DSC) that is created by policy and perpetuates brightened boundaries and healthcare stratification between individuals along this continuum. In the DSC, undocumented immigrants are at one end of the continuum and citizens at the other, with various documentation statuses in between. DSC position determines benefits eligibility, and movement along the continuum constrains or enhances that eligibility. This DSC framework picks up where previous studies outlining the fluidity and impact of documentation status categories left off by demonstrating the alignment of those categories relative to each other and immigrants’ recognition of their disadvantaged status vis-à-vis more privileged others.

A key contribution of this article is centering public policy as essential in the creation of the documentation status continuum in two ways. First, public policy creates the documentation status categories that are the basis of social boundaries facilitating distinctions between individuals based on their documentation status. Second, public policy creates and perpetuates the symbolic boundaries through which societal resources are differentially allocated. Citizens are most privileged relative to all others in this continuum, but permanently documented immigrants also have some privilege relative to liminally legal and undocumented immigrants. By showing these categories in relation to each in the DSC, we can better understand how policy facilitates boundary making between and across documentation status categories.

This article begins by highlighting the civic stratification and boundaries scholarship, which are relevant for understanding how policy generates and reifies category distinctions over time. Next, I explain the DSC framework, showing how policy delineates documentation statuses and their alignment in the present. I then discuss previous DSC configurations aligning with major policy shifts, when the modern US welfare state began, and key 1996 welfare and immigration reforms. Finally, I use data from 207 interviews with immigrants, healthcare providers, and immigrant and health organization employees exploring immigrants’ experiences under the 2006 Massachusetts Health Reform and national 2010 Affordable Care Act (ACA) in Boston, Massachusetts, to show how the present DSC configuration perpetuates stratified healthcare access for immigrants. Both reforms were passed to extend affordable health coverage but reinforced legal distinctions between citizens and noncitizens, entitling them to different provisions based on DSC position (Bustamante et al. 2019; Joseph 2016; Van Natta et al. 2019). Such legal distinctions represent a shifting and brightening of boundaries around individuals, which has been happening in US public policy since the 1970s and has also begun happening in Western European countries receiving larger numbers of migrants (Benson and Lewis 2019; Dourgnon et al. 2023; Fox 2016; Joseph 2020; Tarabusi 2019). The DSC framework is important because it makes visible the invisible hand of documentation status categories and enhances our understanding of documentation status as a salient axis of civic stratification and boundary (re)making in immigrant-receiving societies.

2. Literature Review

Documentation Status, Civic Stratification, and Boundary Making

Scholars have assessed how documentation status shapes immigrants’ lives, negatively influencing health and other outcomes for undocumented and documented immigrants (Gonzales 2015; Menjívar 2006; National Academies of Sciences 2015). Researchers have also found that national governments construct legal citizenship to determine who is entitled to public benefits, generating different categories of belonging (Bloemraad et al. 2019; Schuck 1998; Wimmer 2013). Furthermore, two types of boundaries facilitate inequality and belonging in the boundary literature (Lamont and Molnár 2002; Wimmer 2013). The first type is symbolic boundaries that determine how people are categorized based on characteristics (i.e., nationality and gender). The second type is social boundaries, which determine access to and distribution of resources. Social boundaries can become so powerful that they transform symbolic boundaries. Both social and symbolic boundaries can be “brightened” (made bolder) to elucidate or “blurred” to minimize distinctions between groups (Alba 2005; Lamont and Molnár 2002). At the same time, individuals’ recognition of group boundaries means that they may engage in practices to change their positionality in relation to those boundaries. Boundary scholars refer to this as “boundary crossing” where individuals cross boundaries (Abascal 2020; Alba 2005; Lamont and Molnár 2002; Loveman and Muniz 2007). Furthermore, as people move across boundaries, these boundaries may shift in response, a process referred to as “boundary shifting” (Abascal 2020; Alba 2005; Lamont and Molnár 2002; Loveman and Muniz 2007). The boundary concept has been used to explore group dynamics as related to race, ethnicity, gender, and citizenship (Abascal 2020; Lamont and Molnár 2002; Loveman and Muniz 2007; Wimmer 2013). Wimmer (2013) emphasized the discriminatory role of citizenship in ethnic boundary-making:

Citizenship is the most effective and legitimate institution to discriminate against individuals …Discrimination on the basis of citizenship represents perhaps the most universal and powerful mechanism of enforcing ethnonational boundaries in the contemporary world.

(p. 67)

Building on other boundary scholars’ work, I utilize the DSC concept to more clearly show the central role of policy in creating the symbolic boundaries responsible for allocating resources that brighten and reinforce pre-existing social boundaries between individuals based on documentation status. In the US, recent immigration policy proposals have curtailed the number of individuals allowed to apply for asylum and increased border security while also restricting noncitizens’ access to publicly funded social services (Hesson 2023; Van Natta et al. 2019). Perhaps the most impactful is the lack of comprehensive immigration reform and confusing administrative procedures that limit access to obtaining citizenship. Racialized anti-immigrant rhetoric in the broader society has further stigmatized immigrants of color, blaming them for the country’s economic woes, treating them as criminals, and maligning their “negative” impact on US culture (Chavez 2013; Joseph and Golash-Boza 2021; Menjívar 2021). A similar alignment of noncitizens is also underway in Western European countries that have received an influx of migrants escaping conflict, economic and political instability, and climate change in Eastern Europe, Africa, and the Middle East (Benson and Lewis 2019; Joseph 2020; Sadeghi 2019; Tarabusi 2019). Such marginalization in the US and Western Europe reinforces symbolic boundaries, perpetuating “us–them” dynamics that influence legislators’ policymaking (Jones 2024; Tarabusi 2019). Resulting policies create documentation status distinctions that differentiate access to benefits through state institutions and produce brighter social boundaries of which individuals across documentation status categories are cognizant (Bialas et al. 2024; Joseph, forthcoming; Menjívar and Lakhani 2016). The consequence is differential access to publicly funded social services like health care between citizens and noncitizens.

Other scholars have referred to brightened social and symbolic boundaries as “civic stratification,” facilitating legal discrimination, or “categorical inequality” (Light 2012; Lockwood 1996; Massey 2017; Morris 2003). Scholars have examined documentation status as a basis of civic stratification, arguing that citizenship structures life chances and, correspondingly, social and economic inequality (Massey 2017; Morris 2003; Torres and Waldinger 2015). Torres and Waldinger (2015) argued that citizenship is a social boundary, tying rights and benefits to documentation status. Focusing on health policy, their conceptual framework illustrated civic stratification as concentric circles with citizens in the center, residents (green card holders) in the next circle, temporary workers in the next circle, and undocumented immigrants furthest from the center. Individuals furthest from the center experience most constraints to health care. Torres and Waldinger (2015) empirically showed that undocumented status impedes immigrants’ engagement in cross-border health care. However, their data from 2007—before ACA implementation—limited the assessment of how more recent policy changes influenced their framework or the impact of other documentation statuses on immigrants’ healthcare access.

The DSC framework contributes to existing migration, civic stratification, and boundary scholarship in three ways. First, the framework outlines the historical development of documentation status categories (symbolic boundaries) and shows how policy implementation via benefit allocation (social boundaries) generates civic stratification. Second, the framework demonstrates how the intersection of policy (immigration and health) at different levels (state and federal) influences immigrants’ social services access. Individuals experience degrees of exclusion based on how boundaries are drawn, shifted, blurred, or brightened around them. Immigrants’ recognition of their disadvantage vis-à-vis citizens shows how documentation status—a juridical construction developed through policy—becomes a social construction affecting individuals’ lives and interactions with others and institutions. Lastly, my study design collecting data under shifting policies demonstrates how policy changes stratify social services allocation for immigrants along the DSC.

3. The Documentation Status Continuum Framework

The documentation status continuum is a schema illustrating how documentation status categories are aligned within society, generate boundary making, and perpetuate civic stratification through public policy. More recent scholarship on the construction of categories argued about the centrality of laws and policies in creating and perpetuating categories that generate social boundaries between individuals (Bialas et al. 2024; Kreisberg 2019; Menjívar and Abrego 2024). This DSC framework builds on that work by naming and arranging those categories in relation to each other to make more visible how such categories exist along a continuum. Immigration scholarship generally focuses on the experiences and outcomes of undocumented, liminally legal, and permanently documented immigrants separately (Aptekar 2015; De Genova 2002; Dreby 2015; Gonzales 2015; Gowayed 2022; Menjívar 2006). In explaining the DSC framework, this article aims to outline the range of documentation status categories in relation to each other and how public policy facilitates boundary making between those categories with significant implications for individuals. Morgan and Orloff (2017) referred to the process of making something visible as “legibilization.” Though I focus on the US context in this paper, the categories and framework identified in this paper may also have some parallels with the alignment of individuals in other countries, particularly other immigrant-receiving countries. Often at the federal level of governments, immigration policies are particularly important for the creation and alignment of documentation status categories in the DSC framework. I begin by “legibilizing” those categories by listing which ones exist in US immigration policy between undocumented and citizen.

Table 1. Creation and description of DSC categories.

Category	Other Terms Used	Description and Federal Law Under Which Status Was “Created”	Work Permit	Granted Protections or Benefits	Renewal Required	Path to Naturalized Citizenship	Deportable	Affected by Recent Policies
Undocumented - low priority (children, DACA) - high priority (criminals)	Unauthorized, Illegal	Entered US without authorization, Overstayed Visa, Expiration of Documented Status	No, except DACA	Federal Level: none State Level: depends on state	N/A, except DACA	None without marriage to US citizen, a job offer and sponsorship by a US employer, or a grant of asylum	Yes	DACA: only accepting renewals; Enhanced detentions and deportation focus, DACA may end under next presidential administration
Visas-”Non-immigrant”	Visa Holder	More than 20 types
- Tourist Visa	B visas: pleasure/business	Legally Allows Tourist/business travel for certain time period	No	Federal/State Level: none	Yes in home country	None without marriage to US citizen, a job offer and sponsorship by a US employer, or a grant of asylum	Yes, if expired	Stricter application procedures, may change if travel ban reinstated under next Trump administration
- Work Visa: H2A/B	Agricultural/non-agricultural workers	Seasonal workers to US for certain time period, H2B created by Immigration and National Act of 1952, H2A created by 1986 Immigration Reform and Control Act	Yes	Federal Level: none State Level: depends on state	Yes by US employer	None without marriage to US citizen, a job offer and sponsorship by a US employer, or a grant of asylum	Yes, if expired	Not yet
- Student Visa: F1/M1		Allows students to study at US educational institutions, created as separate non-immigrant category in 1921 exempt from future quotas under 1924 Immigration Act	No, but may apply after education concludes	Federal Level: none State Level: depends on state	Yes by US institution	Must obtain H1B status and then apply for LPR after 6 years	Yes, if expired	Not yet
- Work Visa: H1B	Skilled immigrant workers	Allows workers with advanced degrees to work for 6 years, created by Immigration and National Act of 1952	Yes	Federal Level: none State Level: depends on state	Yes by US employer	Can apply for LPR after 6 years	Yes, if expired	Not yet, may change under next presidential administration
Temporary Protected Status	TPS	Allows people from designated countries with environmental disasters or armed conflict to legally enter US, created by Immigration Act of 1990	Yes	Federal/State Level: yes	Yes by individual, home country status renewed by president	None without marriage to US citizen, a job offer and sponsorship by a U.S. employer, or a grant of asylum	Yes, if expired	Reinstated under Biden administration, may change under next presidential administration
Asylee		Allows people being persecuted based on social group membership to legally enter US, created by United States Refugee Act of 1980 which made it possible to apply for refugee status as an asylee	Yes	Federal/State Level: yes	Yes, home country status renewed by president	Can apply for LPR after 1 year	Yes, if expired	Tightened eligibility criteria, may change under next presidential administration
Refugee		Allows people being persecuted based on social group membership to legally enter US, created by Immigration and National Act of 1952	Yes	Federal/State Level: yes	Yes, home country status renewed by president	Can apply for LPR after 1 year	Yes, if expired	Around 100,000 allowed per year, may change under next presidential administration
Legal Permanent Resident (LPR)	Green card holder	Created under 1940 Alien Registration Act, 1996 Personal Responsibility and Work Authorization Act created distinction between short and long-term LPRs
- Short Term: Less than 5 years		Allows people to legally live and work in US on extended basis	Yes	Federal Level: none State Level: depends on state	Yes, must be renewed every 10 years	Can apply for citizenship after 5 years	Yes, for certain crimes and being public charge	None
- Long Term: More than 5 years		Allows people to legally live and work in US on extended basis	Yes	Federal/State Level: yes	Yes, must be renewed every 10 years	Can apply for citizenship after 5 years	Yes, for certain crimes and being public charge	None
Naturalized U.S. Citizen		Allows immigrants to become US citizens	Not needed	Federal/State Level: yes	N/A	N/A	Usually no, but yes if citizenship revoked for certain reasons	None, may change under next presidential administration
U.S.-Born Citizen		Based on birth in US or to US citizens abroad	Not needed	Federal/State Level: yes	N/A	N/A	No, but citizenship can be revoked for certain reasons	None

Note: Unable to find law under which B visas were “created”.

shows the most common categories and which immigration policies led to their creation along with the related eligibility of public social services, renewal requirements, and paths to citizenship in the US (if any) associated with each category. The information in Table 1 is the most up to date as of 19 December 2024. It is important to note that some of the information in Table 1 could change under the next US presidential administration of Donald Trump after inauguration in January 2025.

Figure 1 is a more simplistic visualization of Table 1 in that it primarily demonstrates the categories in the continuum and their alignment in relation to each other, which goes from left (undocumented) to right (US-born citizen) with multiple statuses in between.3

Undocumented immigrants are on the furthest left of the continuum and most vulnerable for detention and deportation. Many studies examined the marginalization of this group given their sizable numbers (Dreby 2015; Gonzales 2015). High-priority undocumented immigrants, which are listed furthest to the left, are those with criminal records or recently arrived adults who are primary targets for deportation. Low-priority undocumented immigrants, listed to the right of high-priority undocumented immigrants, are children and those with Deferred Action for Childhood Arrivals (DACA) status. These groups have been less of a priority for deportation. DACA is a protected status that allows recipients to obtain work authorization and temporary relief from deportation. DACA does not provide LPR status nor a path to citizenship.4 Given the results of the 2024 US presidential election, it is likely that the second Trump administration will terminate the DACA status, which was attempted under the first Trump administration (Liptak 2019). Thus, DACA recipients will be just as vulnerable to deportation. The bold line between undocumented immigrants and visa holders also symbolizes the brightened symbolic and social boundary between these groups: undocumented immigrants lack legal status and encounter more difficulty adjusting their status.5

To the right of undocumented individuals are tourists, students, and/or work visa holders (Cohen 2015; United States Department of State 2016).6 Visa recipients must depart after their visas expire unless they renew their visas or obtain LPR status. Otherwise, they become undocumented. Tourist visa holders (B-1/B-2) are ineligible for public benefits and have no work authorization. Student visas (F-1 and M-1) are issued to those studying in academic or vocational institutions (United States Department of State 2017a). Different employment visas provide work authorization: H-1Bs for highly skilled workers in specialized occupations and H-2A/Bs for seasonal workers in agriculture, hospitality, or tourism (United States Department of State 2017b). In the DSC, H-2A/B visa holders are to the right of tourist visa holders and to the left of H-1B and student visa holders, who can more easily obtain sponsors for a green card. As temporary employees, H-2A/B visa holders do not receive employment benefits, an important social boundary distinguishing them from H-1A/B visa holders. Student visa holders have institutional support for visa renewal unlike H-2A/B visa holders. All visa holders are ineligible for benefits and deportable beyond their visa expiration date (Fox 2016; Viladrich 2012).

To the right of visa holders are those with temporary protected status (TPS) created under the Immigration Act of 1990.7 TPS recipients enter with temporary legal status for six to eighteen months, which can be extended (Menjívar 2017). There are an estimated 340,000 TPS recipients eligible for work authorization and public health programs for seven years (Menjívar 2017). TPS recipients cannot be detained or deported, but TPS has no path to LPR or citizenship (Menjívar 2017). TPS holders can become undocumented for not renewing their paperwork or the president ending their home country’s TPS designation, creating “liminal legality” for them (Menjívar 2006). The line between TPS recipients and asylees represents TPS recipients’ inability to move to the right. Given that the first Trump presidential administration attempted to end TPS, it is likely that this status may also be at jeopardy under the second Trump administration (Gamboa 2020).

Refugee and asylee status are granted to individuals unable to live in their home countries due to socio-political conflicts or persecution based on race, religion, nationality, or membership in certain groups (FitzGerald 2019; Gowayed 2022). Refugees undergo a rigorous and lengthy application process before arriving, while asylees experience a cumbersome, if not more challenging application process, that is applied after arriving to the country. A significant difference is that refugees arrive with their protected documentation status while individuals applying for asylum may be denied and then vulnerable to deportation. The refugee category was created under the Immigration and National Act of 1952. The asylee category was created under the United States Refugee Act of 1980. Refugees and asylees may apply for LPR status and eventually citizenship. They can receive federal benefits in their first seven years of residence (Fix and Haskins 2002). The line between asylees and refugees indicates the symbolic boundary between these two groups.

To the right of refugees are lawful permanent residents (LPRs—green card holders), the most privileged among noncitizens. Created under the 1940 Alien Registration Act, LPRs can legally and permanently reside in the US and receive work authorization and social security numbers. LPRs may apply for citizenship after three to five years (USCIS 2013). However, the 1996 Personal Responsibility and Work Opportunity Act (PRWORA) brightened social and symbolic boundaries between LPRs based on length of residence. PRWORA implemented a five-year residency bar on LPRs for public benefit eligibility (Fox 2016; Menjívar and Lakhani 2016). The solid line between short-term (less than five years) and long-term (more than five years) LPRs represents a brightened symbolic boundary (via recategorization) and social boundary (via resource reallocation). The 1996 Immigration Reform and Immigrant Responsibility Act (IIRIRA) strengthened border security, criminalized fraudulent immigration documents, and required employment eligibility verification. IIRIRA also allowed states to create their own policies for resource allocation from national publicly funded social services within their jurisdictions (Menjívar and Lakhani 2016). IIRIRA also negatively affected LPRs and other noncitizens, making them deportable for minor offenses and being considered “public charges” (Golash-Boza 2015; Park 2011). A “public charge” is a noncitizen who is deemed likely to become dependent on government assistance (Golash-Boza 2015; Park 2011).

Lastly, US-born citizens are the most privileged and can access benefits if income and/or age eligible. Citizens are also most secure: they have voting privileges and cannot be deported for minor criminal offenses. Naturalized citizens have the same rights as US-born citizens, but misrepresentation on naturalization applications may jeopardize their citizenship and lead to deportation (USCIS 2022). Denaturalization is rare, but this is also something that could shift under the next US presidential administration, particularly amid President-elect Trump’s campaign promises to strip citizenship from those born to undocumented immigrants and subsequently deport them as families (Smith 2024). The dotted line between naturalized and US-born citizens demonstrates this social boundary. Noncitizens, everyone to the left on the continuum, do not have the same privileges and are deportable for minor offenses or being a “public charge” (Golash-Boza 2015; Park 2011).8 The bold line separating citizens and noncitizens represents this bright symbolic and social boundary.

3.1. DSC Categories over Time

The number of DSC categories and their implications for social and symbolic boundaries have shifted over time (Menjívar 2024). No documentation status distinctions existed for obtaining federal benefits when the US welfare state began in 1935 (Fox 2016).9 There were no social boundaries between citizens and noncitizens. All residents—even undocumented immigrants—were eligible for benefits, although states could implement restrictions on jointly funded programs.10 Increased undocumented immigration after the 1924 Immigration Act enhanced southern border enforcement and deportation in the 1930s, increasing undocumented immigrants’ deportability (Ngai 2004). Before 1972, there was no DSC for obtaining publicly funded social services, indicated by no lines or social boundaries in Figure 2. The bold line separating citizens from noncitizens signifies a symbolic boundary denoting categorical classifications between the two groups.

In 1972, Congress barred undocumented immigrants from receiving benefits like Medicaid and welfare, representing a restrictive shift and brightening social boundaries between undocumented immigrants and others (Fox 2016), as shown by the full bold line in Figure 3.

The current DSC was codified with the 1996 IIRIRA and PRWORA reforms (Figure 1), which increased noncitizens’ deportability and significantly curtailed access to publicly funded social services (Fox 2016; Park 2011). Both policies demonstrate how federal policies brightened social and symbolic boundaries based on documentation status compared to previous periods. Scholars have argued that the United States increased the number of temporarily legal statuses over time, impeding immigrants’ ability to obtain residency and citizenship (Cohen 2015; Cook-Martin 2019; Kominers 2016; Menjívar 2024).

3.2. Movement Along the DSC

Movement along the DSC can change one’s access to citizenship and related privileges. While rightward movement increases eligibility for social services and decreases deportability, leftward movement decreases benefits and increases deportability. It is advantageous for individuals on the left to have rightward movement toward citizenship. Those with undocumented, visa, asylee, or refugee status must first obtain LPR status; only then, and after some years, can they apply for citizenship. However, naturalization remains a costly and bureaucratically intensive process (Aptekar 2015; Chen 2020). Without comprehensive immigration reform, many noncitizens will remain in their current position or experience leftward movement (Motomura 2014). Even for immigrants who are eligible to adjust their status, confusing, lengthy, and costly LPR and citizenship application processes leave some documented immigrants in limbo (Aptekar 2015; Chen 2020).

Distinctions within DSC categories are also important for continuum movement. Undocumented immigrants who arrive legally and overstay a visa can more easily adjust their status than those entering without inspection (USCIS 2015). Although undocumented immigrants are most deportable, legal noncitizens are not exempt from deportation or access to benefits (Cook-Martin 2019; De Genova 2002). Documented immigrants may move left and become undocumented after falling out of status. Consequently, all noncitizens are subject to “legal violence” where the federal government sanctions structural and symbolic violence, discriminating based on documentation status (Menjívar and Abrego 2012).

3.3. Relationality Between Categories

DSC categories and individuals in each category exist in relation to one another. A category derives social, symbolic, and political existence compared to other categories. Sociologists have argued that social actors exist relative to each other (Bourdieu and Wacquant 1992; Emirbayer 1997). Social actors along the DSC similarly recognize the (dis)advantages associated with their position compared to others (Bialas et al. 2024; Tuohy 2020).

The federal government creates categories, which subsequently develop a social and structural life of their own and have real consequences for people (Bialas et al. 2024; Menjívar and Abrego 2024). Thus, there can be no undocumented immigrants without documented immigrants or citizens. The (dis)advantages that come with TPS exist in comparison to non-TPS immigrants without similar advantages. In lacking the privileges that come with citizenship, noncitizens are very aware of their vulnerable structural DSC positions (Bialas et al. 2024; Gonzales 2015; Menjívar 2006; Tuohy 2020).

The remainder of this article demonstrates the DSC framework through a qualitative assessment of immigrants’ healthcare access under the Massachusetts and ACA health reforms. I show how documentation status differentially shapes access to health care, social services, and perpetuates civic stratification based on DSC position.

4. Data and Methods

Data come from a study examining how documentation status shaped immigrants’ healthcare access under comprehensive healthcare reform from 2012 to 2013 (under the Massachusetts health reform), 2015 to 2016 (post-ACA implementation), and 2019 (Trump administration ACA repeal efforts and restrictive immigration policies) in Boston, Massachusetts. Boston was an ideal site, as the capital of the first state to implement comprehensive health reform and a traditional but understudied immigrant destination city (Johnson 2015). I interviewed 207 people from three stakeholder groups: immigrants, healthcare professionals, and immigrant and health advocacy organization employees (

Table 2. Immigrants, providers, and IHEs interviewed in 2012–2013, 2015–2016, and 2019 (Total N = 207).

Stakeholder Group	Pre-ACA 2012–2013	Post-ACA 2015–2016 a	Post-2016 Election: 2019 b
Immigrants	N = 31	N = 39	N = 12
- Brazilians	21	15	8
- Dominicans	10	14	2
- Salvadorans	N/A	10	2
Healthcare Providers at Boston Health Coalition	N = 19	N = 19	N = 12
- Physicians	5	6	5
- Medical Interpreters	4	4	2
- Other Medical Staff	10	9	5
Immigrant/Health Organization Employees	N = 20	N = 25	N = 30
- Brazilian	6	4	7
- Dominican	2	4	2
- Salvadoran	N/A	2	2
- General Immigrant Organizations	3	5	9
- Health Organizations	9	7	8
- City/State Officials	0	3	2
Total	70	83	54

a. Salvadorans added to the 2015–2016 sample amid political debates about TPS status renewal. b. 2019 Immigrant Sample is smaller due to recruitment difficulty in socio-political climate.

).

The immigrant sample had 82 respondents: 31 interviewed in 2012–2013, 39 interviewed in 2015–2016, and 12 interviewed in 2019.11 The 2019 immigrant sample was notably smaller than prior years of this study, as that year coincided with the first Trump administration’s explicitly anti-immigrant rhetoric and policies. Some of those policies included the targeted deportation of undocumented immigrants, end of temporary protected status and Deferred Action for Childhood Arrivals (DACA), and resumption of workplace immigration raids. Fear in Boston’s immigrant communities significantly affected recruitment. Each year of the study, I recruited Brazilian, Dominican, and Salvadoran immigrants as they are three of Boston’s largest immigrant groups. Dominicans have migrated since the 1960s and are typically LPRs or naturalized citizens. Salvadorans and Brazilians began migrating in the 1980s. Though some Salvadorans received TPS, Salvadorans and Brazilians are usually undocumented. Brazilians typically arrive with tourist visas and overstay while some Salvadorans enter the US without inspection. Interviews with these groups covered immigrant demographics, self-reported physical/mental health pre-migration and in the US, and healthcare access pre-migration and in the US, as shown in

Table 3. Demographic Characteristics of Immigrants Interviewed in 2012–2013, 2015–2016, and 2019 (N = 82).

Demographics	2012–2013 Immigrant Sample (N = 31)		2015–2016 Immigrant Sample (N = 39)			2019 Immigrant Sample (N = 12)
	Brazilians (N = 21)	Dominicans (N = 10)	Brazilians (N = 15)	Dominicans (N = 14)	Salvadorans (N = 10)	Brazilians (N = 8)	Dominicans (N = 2)	Salvadorans (N = 2)
Gender (# women)	15	5	8	10	6	5	2	2
Median Age (years)	40	55	43	56	40	46	55	34
Average Time in US (years)	12	14	10	21	19	11.5	28	6
Average Individual Monthly Income	$3969	$480	$1720	$843	$1383	$3017	$3050	$1380
Median Individual Monthly Income	$2560	$300	$2000	$640	$1350	$2000	$3050	$1380
Employed at Time of Interview	16	6	11	8	8	6	2	2
Customary Occupations	Hairstylists, Childcare, Cleaning, Education	Childcare, Cleaning	Childcare, Cleaning, Landscaping	Childcare, Restaurants	Childcare, Clerical, Restaurants	Cleaning, Nurse Assistant	Dentist, Housecleaning	Clerical
Documentation Status (at interview) a
Undocumented	6	3	6		6	5		1
DACA						1
Tourist Visa (B1)	2		1
Religious Visa (R1)	1
Student Visa (F1)			3
Work Visa (H1A/B)	1		1
Temporary Protected Status (TPS)	N/A	N/A	N/A	N/A	1
Green Card/LPR	10	4	3	11	2			1
Naturalized Citizens	1	3	1	3	1	2	2
Health Coverage Type b
Uninsured (N)	1		2	2	3	1
Health Safety Net (N)	7	2	4	1	4
MassHealth (N) c	4	6	6	9	2	3		1
Commonwealth/ConnectorCare (N)	1				1			1
Private (N)	8	2	3	2		4	2

a. Blank spaces in the table for this variable indicate that no respondents had those statuses among the different immigrant groups. R1 Visas are for those in religious occupations who will temporarily volunteer with religious organizations. They are also very specialized. b. Blank spaces in the table for this variable indicate that no respondents had those statuses among the different immigrant groups. These specific health coverage types listed will be discussed in Chapter 2. c. Undocumented immigrants with MassHealth coverage had MassHealthLimited, which only covers emergency services.

, which outlines their demographics.

To assess the institutional factors influencing immigrants’ healthcare experiences, I interviewed 50 healthcare professionals at the Boston Health Coalition (BHC)12, a network of safety-net hospitals and clinics providing quality care to marginalized populations. Respondents included physicians, medical interpreters, case workers, or psychiatrists at eight BHC sites. Interviews explored respondents’ challenges serving immigrants, multilingual staff availability, healthcare reform impacts, and health problems of immigrant patients.

Finally, to examine how local socio-political context influenced immigrants’ healthcare access, I interviewed 75 employees of local immigrant and health advocacy organizations (IHEs) that assisted immigrants with insurance and/or social service enrollment. These interviews examined socio-political climate for immigrants, local enforcement of federal immigration policy, and challenges immigrants face living and navigating the healthcare system in Boston.

I recruited respondents through IHE organizations, using purposive snowball sampling amid immigration enforcement concerns during data collection. I recruited male and female immigrants from ages 25 to 60 who were in the country for at least one year and more likely to have used the healthcare system. BHC respondents were medical professionals with immigrant patients, including Brazilians, Dominicans, and Salvadorans. Interviews were conducted in Brazilian Portuguese, Spanish, or English, lasted approximately 60 min, and were audio-recorded and transcribed. I use pseudonyms to protect respondents’ identities.

For analysis, I imported and closely read interview transcripts in NVivo software 14 using grounded theory, which consisted of open and focused coding (Emerson et al. 1995; Glaser and Strauss 1967; Strauss and Corbin 1998). I developed an exhaustive list of codes, one- to three-word phrases that mentioned documentation status categories and described respondents’ perceptions of how documentation status shaped their healthcare and broader experiences. I created sub-codes corresponding to each stakeholder group to make between-group comparisons. I then re-read transcripts and organized words, phrases, and sentences under the associated codes.13

I also analyzed public data on the MA and ACA health reforms to triangulate with the qualitative data and further assess how documentation status shaped coverage options under the policies. I analyzed previous immigration and welfare policies to better understand how they intersected with health policy based on documentation status. This policy analysis was central to DSC framework development and the findings illustrating healthcare stratification by documentation status discussed in Section 5.2.

My access to stakeholder groups allowed me to qualitatively explore Brazilian, Dominican, and Salvadoran immigrants’ experiences which are under-represented in immigration, health, and public policy research.14 Although data were collected in Massachusetts, studies of the Massachusetts Health Reform prior to ACA implementation were used to assess the potential national impact of the ACA. These factors limit the generalizability of the results. But the findings may have implications for populations that are uninsured post-healthcare reform and also affected by shifting subnational and national policies. The findings may be relevant for applicability of the DSC framework to populations and other publicly funded social services beyond those explored in this article.

5. Results

5.1. The DSC at Work Among Boston Immigrants

Interview data revealed that noncitizens along the DSC experienced uncertainty regarding their health coverage eligibility and deportability. BHC healthcare providers and IHEs echoed these sentiments. To begin, I provide an overview of the health coverage options available under the Massachusetts and Affordable Care Act health reforms and how DSC position shaped access to coverage based on my policy analysis of those reforms. Such options align with the DSC and demonstrate how policy generates brighter social boundaries between citizens and noncitizens of various statues. Next, I show how my interview data reflect three aspects of the DSC framework: (1) DSC categories and their impact on healthcare access; (2) role of DSC position, deportability, and healthcare use; and (3) relationality between DSC categories. Collectively, these findings reveal how DSC position generates civic stratification in health care and brightens the social and symbolic boundaries between immigrants and citizens.

5.2. Health Reform and Healthcare Access Along the DSC

In 2006, Massachusetts became the first US state to implement comprehensive health reform to expand health coverage to all its residents regardless of documentation status. The historic reform became the model for the 2010 federal Affordable Care Act (ACA), which expanded eligibility for the federal Medicaid program for lower-income individuals and provided subsidies for middle-income individuals to purchase health coverage in the federal health insurance marketplaces also known as “exchanges.” Though successful in reducing the uninsured population in the US, the ACA represents a brighter separation of immigrants from citizens in healthcare coverage (Joseph 2016; Marrow and Joseph 2015). Adult US citizens, long-term LPRs, refugees, asylees, and TPS immigrants are eligible for provisions. Students and work visa holders are excluded from the Medicaid expansion but can purchase private coverage with no government subsidies in the federal health exchanges. Undocumented immigrants are excluded from the Medicaid expansion and purchasing private coverage in the exchanges.

Immigrants’ exclusion from ACA provisions means a significant number remain uninsured relative to citizens (Bustamante et al. 2019; National Academies of Sciences 2015). Their primary option for care is the nation’s already stressed health safety-net system. My analysis of the MA and ACA reforms indicates that health coverage options fall along the DSC, with undocumented immigrants entitled to the least options and citizens to the most.

Table 4. Immigrants’ documentation status and health coverage in Massachusetts after MA reform and in states where Medicaid was expanded after ACA implementation.

Adult (Ages 21–64) Coverage Based on Documentation Status	MA: After Health Reform (Pre-ACA)	MA: Post-ACA Implementation	ACA in Medicaid Expansion States
Undocumented	Yes: HSN b, MassHealth Limited, Could Purchase Coverage through Health Exchange	Yes: HSN
	No: Health Exchange subsidies	No: Health Exchange subsidies, Cannot Purchase Coverage through Health Exchange	No Coverage
Undocumented Deferred Action Recipients (DACA/Dreamers) a	Yes: HSN	Yes: HSN, MassHealth Family Assistance
	No: Exchange subsidies	No: Exchange subsidies, Cannot Purchase Coverage through Health Exchange	No Coverage
Certain Non-immigrant Visas: student, work, etc.	Yes: HSN, MassHealth Limited, Could Purchase Coverage through Health Exchange	Yes: HSN, MassHealth Limited, Can Purchase Coverage through Health Exchange, ConnectorCare	Yes: Purchase Coverage through Health Exchange
	No: MassHealth Standard, CommonwealthCare	No: MassHealth Standard	No: Ineligible for Medicaid
Temporary Protected Status (TPS)	Yes: HSN, MassHealth Limited, Could Purchase Coverage through Exchange, Commonwealth Care	Yes: HSN, MassHealth Limited, Could Purchase Coverage through Exchange, ConnectorCare	Yes: Purchase Coverage through Exchange
	No: MassHealth Standard	No: MassHealth Standard	No: Ineligible for Medicaid
Asylees, Refugees	Eligible for all if income eligible	Eligible for all if income eligible	Eligible for all if income eligible
Legal Permanent Residents (<5 years in U.S.)	Yes: HSN, Commonwealth Care, Could Purchase Coverage through and Receive Subsidies for Exchange	Yes: HSN, ConnectorCare, Can Purchase Coverage through and Receive Subsidies for Exchange	Yes: Can Purchase Coverage through and Receive Subsidies for Exchange
	No: MassHealth Standard	No: MassHealth Standard	No: Medicaid
Legal Permanent Residents (>5 years in U.S.), Naturalized and US-Born Citizens	Eligible for all if income eligible	Eligible for all if income eligible	Eligible for all if income eligible

^a DACA did not exist under 2006 MA Reform. ^b HSN is the abbreviation for Health Safety Net.

shows coverage options from left to right of the following: (1) Massachusetts under its 2006 health reform; (2) Massachusetts after ACA implementation; and (3) other states after ACA implementation that expanded Medicaid.15 The first column lists the documentation status categories from top to bottom, starting with undocumented and going to US-born citizens. The implementation of the Massachusetts and ACA reforms demonstrate brightened social boundaries and increased stratification in healthcare access for Boston immigrants.

Under the Massachusetts reform (see column 2), state residents could apply for health coverage regardless of documentation status.16 The state-funded Health Safety Net Program (HSN) allowed all eligible low-income residents to obtain preventive and some specialty care at designated facilities. Low income long-term LPRs and citizens were eligible for the state’s federal Medicaid program (MassHealth). Massachusetts also developed a state-funded coverage option (“Commonwealth Care”) for short-term LPRs (ineligible for MassHealth) to purchase subsidized private insurance in the state health exchange. Income-eligible TPS recipients were eligible for all options. Income-eligible students and work visa holders could apply for HSN and coverage through the health exchange but were ineligible for MassHealth and Commonwealth Care. Income-eligible refugees, asylees, long-term LPRs, and citizens could apply for all coverage options.

The MA reform brightened social and symbolic boundaries between Massachusetts residents and those from neighboring states by extending health coverage to all immigrants. Simultaneously, the reform brightened social and symbolic boundaries between federally ineligible residents (i.e., undocumented and short-term LPRs) and federally eligible residents (i.e., long-term LPRs and citizens). The dark grey boxes represent individuals eligible for all options.

The lighter boxes demonstrate fewer options based on DSC position. Distinctions in documentation status and income shaped coverage eligibility.

Once the 2010 ACA was signed into law and implemented, Massachusetts lawmakers recrafted the 2006 reform to keep programs intact (column 3). Programs like HSN and Commonwealth Care remained the same, allowing lower-income undocumented immigrants and short-term LPRs to maintain eligibility. Nevertheless, Massachusetts reduced HSN funding because more low-income long-term LPRs and citizens received eligibility under the ACA’s Medicaid expansion. At the same time, the movement of certain documented immigrants and citizens from HSN to Medicaid represented a boundary brightening between these Massachusetts residents and undocumented immigrants who only had access to HSN. Another consequence of ACA implementation was the further demarcation of the Massachusetts population by documentation status, a necessary step to determine individuals’ health coverage eligibility. The dark and light shaded boxes in column three of Table 4 represent this social boundary demarcation.

Health coverage for immigrants in other US states that expanded Medicaid under the ACA is limited along the DSC due to 1996 PRWORA and IIRIRA policies, which brightened social and symbolic boundaries between most immigrants and citizens (column 4). Undocumented immigrants, visa holders, and short-term LPRs remain excluded from the Medicaid expansion.17 Students and work visa holders and income-eligible short-term LPRs can purchase coverage in the exchanges.18 Income-eligible TPS recipients, asylees, refugees, long-term LPRs, and citizens are eligible for all provisions.

Massachusetts immigrants have access to more health coverage than immigrants elsewhere, except in states like California which used state funds to make undocumented immigrants eligible for its Medicaid program in 2024 (Joseph and Van Natta 2024). But, in Massachusetts, California, and elsewhere, documentation status still determines one’s eligibility for health coverage. Public coverage programs like MA’s HSN and the federal Medicaid program are accepted at fewer locations and physicians can opt out of seeing patients with such coverage (Decker 2012; Luo et al. 2023). Patients with public coverage experience difficulty using it and have “categorically unequal” health care compared to those with private insurance (Light 2012; Luo et al. 2023). DSC position and income generate civic stratification in health care even with coverage, indicating how both factors brighten social boundaries between individuals in the healthcare system.

5.3. Different DSC Categories and Their Impact on Healthcare Access

As shown in the previous section, an individual’s documentation status position along the DSC shapes their eligibility for publicly funded social services like health care. In this study, immigrants, providers, and advocates discussed how this shaped immigrants’ healthcare access in Boston. Immigrant respondents were very clear about how documentation status shaped their eligibility, especially if their status changed, which, in turn, reconfigured their eligibility.

On the other hand, providers and IHEs reported that many people were confused about how documentation status affects eligibility for health coverage due to the following reasons: (1) lack of knowledge about the range of categories that exist and (2) overlapping and conflicting local, state, and national laws that outline different eligibility criteria.

With regard to immigrants’ clarity about the impact of their DSC position on eligibility for health coverage, a Brazilian immigrant named Maria that I interviewed in 2013 discussed the shift in her coverage options. Maria had arrived on a tourist visa and overstayed, which resulted in her becoming undocumented. Because of her status and income, she was unable to receive coverage for her extensive respiratory conditions in the US:

I knew I wouldn’t have access to medical [coverage]…because of my paycheck I wasn’t eligible. So, I was in this limbo because I could not apply for Commonwealth Care [MA Health Insurance]. Every time I would go [to the doctor] I thought I would get a $2000 bill. When you are illegal you are afraid. Finally, this year after [getting] the green card, me and my husband got Commonwealth Care.

Though undocumented, Maria’s income was too high to qualify for MA’s Health Safety Net program (HSN) available to all low-income residents. But she was also ineligible for the state’s Commonwealth Care because of her documentation status. After obtaining her green card (LPR status) through marriage, she became eligible for Commonwealth Care, demonstrating how social boundaries between undocumented and LPR status as well as income both excluded and included Maria. Maria’s case reveals how rightward movement along the DSC improves access to benefits associated with “legal” status, at least in the state of Massachusetts. At the same time, Maria remained ineligible for federal ACA coverage because she had not yet met the five-year bar for her LPR status. Thus, Maria’s case also demonstrates the complexity of different eligibility criteria associated with documentation status between state- and federal-level health coverage programs. This complexity illustrating brighter social boundaries of exclusion has disproportionately contributed to immigrants in Massachusetts and other states being excluded from health coverage.

The complexity outlined in Maria’s case also demonstrates how confusion can arise from different documentation status eligibility criteria between the state and national policies. Much of that confusion can also be tied to the range of documentation statuses that exist along the DSC. My 2015 interview with Kelly, an IHE interviewed in 2015, revealed both types of confusion:

One of the biggest frustrations I’ve dealt with is when I get calls from clients that say, “I went to a community health center to get help and I was turned away because I’m undocumented.” There are some people, that are hired to be assisters [with health coverage enrollment] to help people apply, but they are not necessarily trained to understand the difference between an asylee seeker, a person that actually has a [asylee] case pending, and that actually is an asylee. Those are three different statuses and some people don’t actually understand how to deal with different immigration statuses. And that’s not covering the thirty, forty other immigration statuses that exist.

Kelly’s quote demonstrates how the complexity of documentation statuses shapes social services eligibility. Even street-level bureaucrats whose jobs are to connect people with services do not understand the range of statuses or their eligibility for health coverage. Beyond that, some of these bureaucrats do not understand that while undocumented immigrants are ineligible for federal health coverage programs like Medicaid, they are still eligible for some health coverage options under Massachusetts law. Confusion about conflicting eligibility under state and federal policy resulted in immigrants being denied access to health coverage. Other research highlights the role street-level bureaucrats have in denying access to services based on eligibility knowledge (López-Sanders 2017; Marrow and Joseph 2015).

Another way that DSC position shapes social service eligibility is tied to an aspect of immigration law called public charge that has existed for the last century. The US government determines the likelihood that a person applying for lawful permanent residency will use public benefits and thus become a “public charge.” Certain types of public benefits count as part of public charge while others do not. Confusion about “public charge” benefits among immigrants, providers, and advocates was mentioned quite often over the course this study. For example, a BHC provider named Kevin that I interviewed in 2012 shared:

I don’t pretend to know all the ins and outs but definitely there is the issue all along, like the people who are trying to work on, towards citizenship, there’s … a[n] urban myth … that if they would use services without being documented, then that will count against them when they are [applying].

Kevin is referring to the public charge designation though he refers to it as an urban myth. He has heard from patients about how one’s DSC position might shape whether one is considered a public charge for using social services and how this could affect their naturalization prospects. In actuality, Kevin is incorrect about two aspects of the public charge determination referenced in his quote. First, it does not apply to undocumented immigrants but only to those applying for lawful permanent resident status before arriving to the US. Second, the public charge determination does not affect people who already have lawful permanent residency status and are applying for naturalization/citizenship.

The public charge determination received more attention under the Trump administration, which aimed to make public charge more restrictive for low-income immigrants in 2019. Under the proposed rule change, US immigration officials were granted more leeway to deny lawful permanent residency to lower-income applicants. But the various aspects of the public charge determination and which DSC categories it applied to generated much confusion. A BHC provider named Reagan that I interviewed in 2019 described how the perception of public charge among immigrants with a range of statuses influenced their decision to apply for social services:

Public charge is hotly debated right now, in terms of folks who are in process to become permanent residents or citizens. But the use of public services is already being used against folks who received those services while, on a temporary visa, some sort of tourist visa, a student visa, and it is being used at consulates abroad to deny visa renewal.

A major consequence of the confusion stemming from these categories and health coverage eligibility is that immigrants are denied or refuse to apply for services even though they may be eligible. This is probably why Latinx immigrants in Massachusetts and across the US are still more likely to be uninsured (Joseph, forthcoming; Ortega et al. 2018).

5.4. DSC Position, Deportability, and Healthcare Use

Studies show that undocumented immigrants’ vulnerability for detention and deportation is magnified when accessing social services like health care (López-Sanders 2017; Marrow and Joseph 2015). Documented noncitizens experience similar fear of detention and deportation (Joseph, forthcoming). This was especially the case for “liminally legal” immigrants who experience precarity because of their temporary legal status. This fear stemmed from concerns that obtaining health services could attract the attention of immigration officials and increase immigrants’ vulnerability of deportation in two ways. First, concerns about information sharing between healthcare facilities and other government agencies resulted in immigrants either not enrolling in or disenrolling from health coverage and other services to which they already had access. Second, intensifying anti-immigrant rhetoric and enforcement threats made immigrants afraid to leave their homes and receive needed care, even if they had health coverage. According to my various stakeholders, there was a clear link in immigrants’ minds between deportability and healthcare use. While this was a consistent finding in my interviews over the course of the study, I highlight quotes from 2019 in this section to demonstrate how the more explicitly anti-immigrant rhetoric and policy of the first Trump administration negatively affected immigrants’ healthcare access.

A Brazilian immigrant named Alexandre that I interviewed in 2019 spoke directly about how fear of enforcement shapes healthcare use for immigrants of various statuses. He specifically describes how concerns about perceived information sharing across healthcare and other sectors produces a chilling effect in immigrants’ healthcare enrollment and service use:

There are many Brazilian immigrants and from other nationalities that are afraid to go to hospitals. I don’t know if it’s President Trump or Congress [who did this] but when you apply for your green card or citizenship, the government will see if you got health care “medical help” or anything else [public benefit], that could negatively affect you[r chances]. So, that’s why many are not going to the doctor, or are afraid to.

Alexandre’s quote alludes to the previously discussed public charge rule and his perception of how it shapes immigrants’ healthcare decisions. Though Alexandre references immigrants applying for their green cards or citizenship, he could be referring to immigrants who are undocumented, have a liminally legal status, or are green card holders. Their noncitizen DSC position has a direct impact on the extent to which they engage with the healthcare system. More importantly, they do not want to increase their vulnerability to deportation by doing so.

With regard to the second way that fear shapes immigrants’ healthcare decisions—through not obtaining needed care—a BHC staff member named Gloria that I interviewed in 2019 spoke with me at length about how this plays out among her patients. Threats of and actual immigration raids as well as enforcement hotspots around the city cause immigrants to alter their health-seeking behavior:

People hear that there will be immigration raids. So, and then I call and say, to the ones that have booked an appointment with me [and don’t show up]: “Well, what happened? You had an appointment.” [The patient:] “Oh, I hear about raids.” And the people who live, like in East Boston, or the ones who have to go through Sullivan Station, because the clients tell me that those that are immigration hotspots for ICE [Immigration and Customs Enforcement].

According to Gloria and other stakeholders I interviewed, living in neighborhoods that are or having to travel through immigration enforcement hotspots increases the likelihoods that patients will not come for care. The fear of possible detention or deportation in route to healthcare facilities is strong enough to make immigrants stay home.

An IHE named Jeff that I also interviewed in 2019 spoke about the health implications of immigrants’ fear of deportability for accessing health care:

So, like, people are not getting prenatal care. Okay, so this is a big one. If people are not showing up for follow up around diabetes, I mean, there’s a whole range of things where maintaining your health is crucial. I was thinking diabetics and other people like with heart pumps or high blood pressure, you want to have a regular interaction with the health care provider, or the system at least. And if people are too scared to come in for visits, that’s all that they miss.

As Jeff’s quote demonstrates, these calculations may have severe health consequences for noncitizens of various statuses (Joseph, forthcoming; Van Natta 2023). Other research suggests that some immigrants try to limit such enforcement by removing themselves from social services they are eligible for by not being embedded in public benefits systems (Asad 2023).

5.5. Relationality Between DSC Categories

Beyond influencing eligibility for health coverage and fear of deportation, DSC position also contributes to an awareness of one’s documentation status relative to others in the continuum. This is especially the case for those towards the left in the DSC who clearly recognize their structural and social disadvantages compared to those further to the right in the DSC. Immigrant respondents were acutely aware of DSC positions to their left and right and the bright social and symbolic boundaries accompanying each category. Such boundaries between undocumented immigrants relative to LPRs and citizens affected social service eligibility, fear of law and immigration enforcement, and general peace of mind. Tuohy (2020) discussed a similar process of how documentation status shaped immigrants’ recognition of their marginalized status relative to others for accessing health care under the ACA in Chicago. In Boston, Carlos, an undocumented Dominican interviewed in 2013 discussed how status constrained his opportunities compared to his LPR relatives before ACA implementation:

My family is here, they came legally with residency (LPR) status, different from me because I was illegal. They arrived with the doors wide open. Since they arrived, they could get work, apply and get apartments. They arrived good. Here I have suffered so much because [of] all this depression and so much stress.

Carlos’ disadvantaged position, compared to his family members, also adversely affected his mental health.

Daniela, a Salvadoran immigrant with TPS interviewed in 2016, stated how she received more benefits than undocumented Salvadorans:

My case wasn’t as difficult because I have had TPS since I came, they [government] gave me a driver’s license. That’s helped me a lot as there are immigrants with no licenses and it’s hard for them to find work. I have had health insurance since being in this country. Most of the people I know don’t have a social security number. So, they get very sick and use homemade remedies. They worry a lot, they drive around [illegally], are anxious about so many things.

Despite being in a privileged DSC position relative to undocumented immigrants at the time of our 2016 interview, Daniela’s liminal legal status was jeopardized in 2019 when the Trump administration ended TPS for Salvadorans and other nationalities. She moved left in the DSC and was recategorized as undocumented, increasing her deportability. This policy shift indicates how the symbolic boundary (category) around TPS could be removed, affecting the resources (social boundary) to which this population had access. These boundary reconfigurations further highlight TPS recipients’ disadvantages relative to citizens.19

Charles, a naturalized citizen from Brazil interviewed in 2016 shared how being a citizen provides freedom that he lacked when he was undocumented:

It’s different [being a citizen] because for the immigrant who has papers, he can live without worry. I walk without fear now. Before when I was undocumented, I was so afraid. Today, the police can stop me and I can give him my driver’s license. He will give me a ticket that I can pay [instead of detaining me]. Whoever doesn’t have a license or green card, they are more afraid.

This recognition of their relative advantage or disadvantage vis-à-vis others in the continuum can bring relief or anxiety depending on one’s position. In this study, immigrants of various statuses were acutely aware of the DSC status distinctions that affected various aspects of their lives. Naturalized citizens like Charles did not take their citizenship for granted and often reflected on how their previous status generated more exclusion in applying for social services, interactions with law and immigration enforcement, and in their search for employment and housing.

6. Discussion

This article has legibilized the range of documentation status categories between undocumented and citizen that exist along a documentation status continuum in the US. One’s position in this continuum determines their eligibility for publicly funded social services. Laws and policies create classes of individuals along the DSC and generate civic stratification. Despite their intent to expand health coverage, the Massachusetts and national Affordable Care Act health reforms perpetuated citizen–noncitizen distinctions. Documentation status operates as a master status, affecting people’s life chances through macro-level policies. Building on studies exploring documentation status as a basis of civic stratification, as important contribution of the documentation status continuum framework is that it elucidates existing documentation status categories and their relationality to each other and demonstrates the central role of policy—at the state and national levels—in brightening social and symbolic boundaries between citizens and noncitizens.

I began this article by drawing attention to Menjívar’s (2023) and Bialas et al.’s (2024) recent articles about the socio-political construction of diverse documentation status categories. This article answered that call by making visible documentation status categories, showing how they have changed over time, and highlighting the alignment and relationality between those categories in the documentation status continuum. This is important for further demonstrating how and why documentation status matters in immigrant-receiving countries that are becoming more and more hostile towards migrants and even citizens perceived as foreign threats. I now close by returning to Bialas et al.’s (2024) call to shift “towards a more situational, contextual understanding of categorization” (12). I do so by highlighting three implications of documentation status categories in the DSC for individuals and groups in society: (1) stratified citizenship and place; (2) immigrant incorporation; and (3) intersection of documentation status with other socio-structural positions. Each implication perpetuates exclusion, stratification, and inequality and should be examined in future research.

My assessment of documentation status and health coverage eligibility highlights how place generates stratified citizenship, as legal citizenship does not guarantee access to citizenship privileges (Bloemraad et al. 2019). The MA and ACA reforms show distinctions between subnational and national policies, influencing boundary brightening between individuals in different DSC categories based on place. The Boston case illustrates this via its immigrant-inclusive policies alongside restrictive national policies. Massachusetts drew social boundaries around all of its residents, providing immigrants more access (albeit still stratified by documentation status) than the national government. But ten US states’ decision not to expand Medicaid under the ACA demonstrates how place stratifies and even limits citizens’ eligibility. Citizens in those states are excluded—like many noncitizens—from Medicaid and some other ACA provisions, illustrating how social boundaries can also be drawn around or blurred between citizens and noncitizens depending on context. Subnational jurisdictions are encoded in geography, making place important for understanding stratified citizenship despite DSC position. Overlapping and conflicting national and subnational laws have created confusion regarding which laws should be followed and which jurisdiction one’s DSC position should adhere to (Marrow and Joseph 2015; Varsanyi et al. 2012). This shapes access to publicly funded social services and other resources.

Beyond the US, policies regarding the provision of publicly funded social services are becoming more restrictive in other Global North immigrant-receiving countries. More wars, political instability, economic uncertainty, and climate change have driven flows of migrants from the Global South. In turn, Global North governments have responded by militarizing their borders, scapegoating migrants, and restricting migrants’ access to their social safety nets that have typically been more generous than those in the US. Thus, while the names of documentation status categories in those countries may differ from those in the US, there is likely a similar alignment of categories between undocumented and citizen that shape social services access and lived experiences in other places.

My DSC framework further demonstrates how citizen–noncitizen distinctions in policy may hinder immigrant incorporation and facilitate transnational ties to counter exclusion (Levitt et al. 2023; National Academies of Sciences 2015; Waldinger 2017). Immigrants’ exclusion from publicly funded social services limits their integration into local institutions and systems that could aid in their social mobility. Such exclusion may also engender reliance on transnational networks for alternative healthcare and social service provision. Long-term LPRs and naturalized citizens’ legal inclusion further allows for formal health coverage and other social services in host and home countries, but other noncitizens are more disadvantaged (Levitt et al. 2023). Rightward DSC movement blurs and removes social boundaries, improving mobility (i.e., obtaining driver’s licenses) and social outcomes, while leftward movement does the opposite. DSC position is also important within mixed-status families and communities as policy also generates interfamily stratification that decreases household social services access and creates familial tensions (Castañeda 2019; Enriquez 2015). This article focused on how policy generates boundary making and its impact on immigrants’ access to health coverage. Future research should also explore how immigrants’ perceptions of their movement along the DSC influences their incorporation and ability to move across social and symbolic boundaries throughout the life course. This will be important for understanding migrants’ strategies for and impact of boundary crossing in their lives.

Third, documentation status interacts with other social positions, which together affect boundary-making and resource allocation through public policy (Bloemraad et al. 2019; Wimmer 2013). Age, gender, and income influence benefits eligibility (Bialas 2024; Joseph, forthcoming). Consequently, individuals’ social positions yield distinctions between people in the same documentation status. For example, undocumented women can access emergency Medicaid for prenatal care during pregnancy but lose coverage two months after delivery. Thus, gender brightens social boundaries (resource allocation), separating undocumented women from men in the same DSC position (symbolic boundary). Due to race and ethnicity, citizens of color experience similar encounters with law and immigration enforcement as their immigrant counterparts (Epp et al. 2014; Golash-Boza 2015; Selod 2018). Various scholars, including Menjívar (2021), have begun describing how racialized legal status—the intersection of race and legal status—disadvantages immigrants and citizens of color relative to those racialized as White (Asad and Clair 2018; Flores and Schachter 2018; Joseph and Golash-Boza 2021). Consequently, documentation status alongside other socio-political categories demonstrate how social and symbolic boundaries can be brightened and blurred based on one’s social position.

Finally, I would be remiss to close without acknowledging that the DSC as discussed in this paper could change in light of the 2024 US presidential election. Just as I showed earlier configurations of the continuum in US history, the most current configuration may change, particularly after President-Elect Donald Trump is inaugurated as the 47th President of the United States in January 2025. Given his campaign promises to have mass deportations, end birthright citizenship, and likely end liminally legal statuses like temporary protected status and DACA, another DSC reconfiguration could be underway. As other Western immigrant-receiving countries shift further to the right politically, similar boundary brightening, shifts, and (re)making may also occur. Only time will tell how these processes may play out and what the implications may be for the social and symbolic boundaries that align with the documentation status categories in the continuum.

7. Conclusions

Public policy facilitates a “documentation status continuum” that highlights an intensifying citizen-noncitizen divide for obtaining public benefits. Using anecdotal evidence from stakeholders in Boston amid healthcare reform, I legibilized the range of documentation status categories that exist and shown how their alignment in relation to each other generates stratification and boundary making in healthcare access. Citizens are most privileged while noncitizens of various documentation statuses are disadvantaged and deportable. Boundaries between citizens and noncitizens are brightening, with consequences for civic stratification and inequality in the US and beyond.