At the turn of the 2020s, immigrant health care in the United States lies at the crossroads of two broken, contradictory and highly politicized systems. US immigration policy embodies the polar opposites of openness – ‘We are a nation of immigrants’ – and exclusion – ‘Build the wall’. The health care system is notorious for being the most expensive in the world, while leaving millions uninsured and vulnerable.

Since the nation's beginnings, US immigration policies have treated newcomers as potential threats to both public health and the health care system. Fears that immigrants bring disease have led to various types of exclusions, inspections, quarantines, deportations and discrimination. There is a rich historical literature on this subject, whereas this chapter focuses on a different type of scapegoating: blaming immigrants for the costs, failures and crises of the US health care system. Since the 1970s, the politics of blame at the intersection of two broken systems has led to a convoluted policymaking in which immigration policies are intended to fix problems in the health care system, and health policies attempt to address perceived immigration crises. In shifting responsibilities, or ‘passing the buck’, between the health care and immigration systems, policymakers have avoided addressing fundamental problems in both.

Although it has taken many different forms, the scapegoating of immigrants as burdens on the health care system has a long history. Starting in colonial times, the barring or expulsion of immigrants who use or might use government-funded welfare services – known as ‘public charge’ doctrine – has been central to US immigration policy. For example, newcomers admitted to public hospitals could be reported by hospital authorities for deportation. Public charge doctrine, as both official policy and informal practice, was used to devastating effect during the Great Depression of the 1930s to deport and ‘repatriate’ hundreds of thousands of Mexicans and Mexican Americans. This is one glaring example of how public charge policies were often used selectively against particular national or ethnic groups.

However, from World War II until the 1970s, the politics of immigrant scapegoating focused more on employment than on welfare or health care issues. Federal investigations of migrant labour and the Bracero guest worker program (established under the Roosevelt administration in 1942) highlighted concerns that foreign-born labourers (primarily from Mexico and the Caribbean – immigration from most other regions had been severely restricted since 1924) drove down wages and took jobs from American citizens.