Still left out: healthcare stratification under the Affordable Care Act

ABSTRACT

The 2010 Affordable Care Act (ACA) increased healthcare access for many Americans. But, its exclusion of most noncitizens and imperfect state-level implementation stratified coverage by documentation status, place, income level, race, and ethnicity across the U.S.A. Drawing from the sociological literature on boundaries, this paper argues that these demographic boundaries facilitate de jure and de facto stratification for immigrants and low-income Americans of various ethnoracial backgrounds. Using existing survey research regarding national ACA implementation and a qualitative study of ACA implementation in Boston, MA, this paper shows how such stratification may worsen existing disparities in healthcare coverage and access among the U.S. population. Implications regarding President Donald Trump and conservative lawmakers’ plans to repeal the ACA are also discussed. The paper contributes to researchers’ understanding of how public policies produce boundaries by place, documentation status, race, ethnicity, and income that facilitate inequality.