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How Policy Shapes Health: Immigration, Exclusion, and Inequality in the U.S.
On April 10, the Schroeder Center for Health Policy hosted Dr. Molly Dondero, an associate professor of sociology at American University, for a discussion on how immigrant policy shapes health outcomes across the life course. Drawing on her research, Dondero explored how systems of exclusion embedded in policy, institutions, and social environments produce measurable health disparities among immigrant populations in the United States. At the center of her work is a key question: how does exposure to exclusion influence immigrants’ health?
Dr. Dondero described “exclusion” as a dynamic, multi-dimensional process rooted in unequal power relationships, operating across economic, political, social, and cultural dimensions. These processes unfold at multiple levels, from individual experiences of fear or discrimination to broader state and federal policy environments. She emphasized that understanding immigrant health requires examining how these layers interact rather than focusing solely on individual behaviors.
She contextualized the discussion of immigrant health by touching on the long history connecting immigration, health, and exclusion in the U.S. Historically, immigrants have frequently been treated as potential threats to public health, from colonial-era quarantine laws and invasive inspections to the fumigation of Mexican workers in the mid-20th century and more recent policies such as Title 42 during the COVID-19 pandemic.
Over time, however, scholarly thinking has shifted from viewing immigrant health as a basis for exclusion to understanding it as a consequence of exclusion. This shift is informed in part by the “immigrant health advantage,” a pattern in which immigrants often arrive in relatively good health despite lower socioeconomic status. That advantage tends to decline over time and across generations, pointing to the role of structural conditions in shaping health outcomes. Rather than being driven only by individual choices, these patterns suggest that policy environments play a critical role in determining long-term well-being. Dr. Dondero described this phenomenon as a “puzzle” that has driven researchers to try to understand the role of particular environmental factors in contributing to this relative decline in health.
A central focus of Dr. Dondero’s research is how variation in state-level immigration policies affects health care utilization and broader engagement with institutions. Using data from the Survey of Income and Program Participation, her work assigns states a policy restrictiveness score based on enforcement practices, access to public benefits, and integration policies targeted towards immigrants. The result is a patchwork of policy environments across the country, where immigrants’ experiences vary significantly depending on where they live.
Her findings show a consistent relationship: as policies become more restrictive, immigrants are less likely to access health care, including doctor visits, health insurance, and public benefits. Similar patterns appear among children, particularly those in first-generation immigrant families, and extend beyond health care to everyday institutions such as banking. These effects are most pronounced among first-generation and low-income immigrants, underscoring how policy environments can reinforce inequality.
Dr. Dondero also emphasized that the effects of exclusion accumulate across the life course, shaping outcomes from birth through older age. She pointed to research showing that babies born to Latina mothers after the 2016 election had significantly lower birth weights, a key indicator of neonatal health. More broadly, exclusion influences child development, mental health, access to care, and physical health outcomes later in life.
She also discussed some of the challenges of studying immigrant health. Policy environments are complex and operate across federal, state, and local levels, often with overlapping or conflicting effects that make the impacts of specific policies difficult to measure. Researchers must also account for both direct policy impacts and indirect effects, such as individuals foregoing medical care due to fear of enforcement, which can be difficult to measure. These challenges are compounded by increasing survey nonresponse among immigrant populations and reduced access to federal data on immigration enforcement. In response, Dr. Dondero described how researchers and organizations are turning to alternative data sources and rapid-response surveys to better capture information about immigrants. Dondero also noted the growing importance of community-based organizations and informal support networks in supporting immigrant health.
Dr. Dondero’s talk illuminated the fact that immigration policy is inherently health policy. By shaping access to resources and engagement with institutions, policy environments play a critical role in determining health outcomes. The study of immigrant health offers a powerful lens for understanding broader patterns of inequality and the role of power in shaping population well-being.