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Examining the health impact of local and state safety-net and immigration policies in infancy and childhood in the United States
Dissertation

Examining the health impact of local and state safety-net and immigration policies in infancy and childhood in the United States

Alexandra E. Eastus
Doctor of Philosophy (Ph.D.), Drexel University
Jun 2026
DOI:
https://doi.org/10.17918/00011393
pdf
Eastus_Alexandra_20261.44 MB
PDF Embargoed Access, Embargo ends: 30 Jun 2028

Abstract

Immigration policies Safety-net disparities Safety-net policies
Introduction: U.S. safety-net programs reduce poverty by providing food, housing, and health assistance, yet access to these programs is shaped by state-level policy variation in administrative burden, benefit generosity, and eligibility rules. These policies may not operate equitably across populations, particularly among immigrants and individuals socially proximal to immigrant communities, who may face both formal restrictions and informal barriers related to immigration enforcement and institutional distrust. Methods: This dissertation examined how state safety-net policy environments influence health and social outcomes and whether these associations are modified by immigration policy and enforcement contexts. Across three aims, I leveraged a novel longitudinal policy index of state safety-net policy robustness capturing administrative burden, benefit generosity, and eligibility rules across seven major programs (2016-2019). Aim 1 used state-level natality data and mixed-effects binomial models to assess associations with low birthweight (LBW) and preterm birth (PTB), stratified by maternal nativity and state sanctuary policy context. Aim 2 used National Survey of Children's Health data and mixed-effects logistic regression to examine forgone care among low-income children, with effect modification by sanctuary policy context and household nativity. Finally, Aim 3 used American Community Survey data and mixed-effects ordinal logistic regression models to assess multi-program participation among households with young children, with effect modification by county-level immigration enforcement intensity. Results: More robust safety-net policy environments were associated with improved outcomes across multiple domains, although effects varied by population and immigration policy context. In Aim 1, a one standard deviation (SD) increase in policy robustness was associated with lower rates of preterm birth among infants of mothers born outside the United States (aIRR: 0.97; 95% CI: 0.93, 0.99). No significant associations were observed among infants of U.S.-born mothers. In Aim 2, a one-SD increase in policy robustness was associated with lower odds of forgone care among low-income children overall (OR: 0.76; 95% CI: 0.46, 0.85) and among children in first- and second-generation households (OR: 0.38; 95% CI: 0.18, 0.82). In Aim 3, more robust policy environments were associated with greater multi-program participation (3+ programs) among likely-eligible households (<200% federal poverty level), with stronger associations observed in counties with higher immigration enforcement intensity, on average, and among immigrant and mixed-status households (1st and 2nd generation). Conclusion: State safety-net policy environments are important determinants of health and social outcomes for low-income children, but their effects are not uniform. Rather, their impact depends on broader immigration policy and enforcement contexts, as well as population characteristics, including nativity and household composition. These findings highlight that social and immigration policies function as interconnected systems that jointly shape access to resources, institutional trust, and population health. Efforts to improve health equity should consider not only strengthening safety-net policies (e.g., reducing administrative burden, increasing benefits, and expanding eligibility rules), but also aligning them with immigration policy environments to ensure that eligible populations are able -- and importantly, willing -- to enroll and utilize public programs. Finally, we investigate public program participation, defined as an ordinal variable to measure no participation, participation in one program, and participation in more than one public assistance program in Aim 3. The posited mechanism is the degree of stress and fear related to immigration enforcement and risk of deportation, with heightened stress and fear due to anti-sanctuary policies and familial separation increasing the likelihood of public program participation. In this third aim I will assess the association between state safety-net policy robustness and public program participation, stratified by the number of detainer requests issued at the county level. Broadly, this dissertation seeks to identify how co-occurring safety-net, immigrant policies, and immigration enforcement activities differentially impact health and social outcomes in households with and without infants and children under the age of 5.

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