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Drawing on interviews with health care workers in three U.S. states from 2015 to 2020, I ask how federal citizenship-based exclusions within an already stratified health care system shape the clinical trajectories of noncitizens in safety-net institutions. Focusing specifically on cancer care, I find that increasingly anti-immigrant federal policies often reshape clinical practices toward noncitizens with a complex, life-threatening condition as they approach a \u201cspecialty care cliff\u201d by (1) creating time penalties that keep many noncitizens in a protracted state of injury and (2) deterring noncitizens from seeking care through threats of immigration enforcement. Through these processes, medical legal violence also creates the potential for moral injury among health care workers, who must adapt clinical practices in response to socio-legal boundaries of belonging.<\/jats:p>","DOI":"10.1177\/00221465241254390","type":"journal-article","created":{"date-parts":[[2024,7,27]],"date-time":"2024-07-27T03:08:05Z","timestamp":1722049685000},"page":"109-123","update-policy":"https:\/\/doi.org\/10.1177\/sage-journals-update-policy","source":"Crossref","is-referenced-by-count":7,"title":["Second-Class Care: How Immigration Law Transforms Clinical Practice in the Safety Net"],"prefix":"10.1177","volume":"66","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-9749-7815","authenticated-orcid":false,"given":"Meredith","family":"Van Natta","sequence":"first","affiliation":[{"name":"Department of Sociology, University of California Merced, Merced, CA, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"179","published-online":{"date-parts":[[2024,7,27]]},"reference":[{"key":"bibr1-00221465241254390","doi-asserted-by":"publisher","DOI":"10.1016\/j.jemep.2021.100661."},{"key":"bibr2-00221465241254390","doi-asserted-by":"publisher","DOI":"10.1080\/15265161.2016.1214315"},{"key":"bibr3-00221465241254390","doi-asserted-by":"publisher","DOI":"10.1146\/annurev-publhealth-032013-182419"},{"key":"bibr4-00221465241254390","volume-title":"Constructing Grounded Theory","author":"Charmaz Kathy","year":"2014","edition":"2"},{"key":"bibr5-00221465241254390","doi-asserted-by":"publisher","DOI":"10.4135\/9781412985833"},{"issue":"1","key":"bibr6-00221465241254390","first-page":"10","volume":"16","author":"Davies Anita A.","year":"2010","journal-title":"Eurohealth"},{"key":"bibr7-00221465241254390","doi-asserted-by":"publisher","DOI":"10.1080\/01419870.2013.783710."},{"key":"bibr8-00221465241254390","doi-asserted-by":"publisher","DOI":"10.1525\/9780520958685"},{"key":"bibr9-00221465241254390","doi-asserted-by":"publisher","DOI":"10.1097\/ACM.0000000000004536"},{"key":"bibr10-00221465241254390","volume-title":"Society Must Be Defended: Lectures at the Coll\u00e8ge de France 1975\u20131976","author":"Foucault Michel","year":"1997"},{"key":"bibr11-00221465241254390","doi-asserted-by":"publisher","DOI":"10.1177\/0731121417743728"},{"issue":"3","key":"bibr12-00221465241254390","volume":"61","author":"G\u00f3mez Cervantes Andrea","year":"2020","journal-title":"Journal of Health and Social Behavior"},{"key":"bibr13-00221465241254390","doi-asserted-by":"publisher","DOI":"10.1001\/jamainternmed.2016.8870"},{"key":"bibr14-00221465241254390","unstructured":"Haley Jennifer M., Kenney Genevieve M., Bernstein Hamutal, Gonzalez Dulce. 2020. \u201cOne in Five Adults in Immigrant Families with Children Reported Chilling Effects on Public Benefit Receipt in 2019.\u201d Urban Institute. https:\/\/www.urban.org\/research\/publication\/one-five-adults-immigrant-families-children-reported-chilling-effects-public-benefit-receipt-2019."},{"key":"bibr15-00221465241254390","doi-asserted-by":"publisher","DOI":"10.1016\/j.ypmed.2019.105755."},{"key":"bibr16-00221465241254390","doi-asserted-by":"publisher","DOI":"10.1016\/j.healthplace.2022.102822."},{"key":"bibr17-00221465241254390","doi-asserted-by":"publisher","DOI":"10.1080\/07481187.2020.1771852"},{"key":"bibr18-00221465241254390","volume-title":"Clinical Practice Guidelines We Can Trust","author":"Institute of Medicine","year":"2011"},{"key":"bibr19-00221465241254390","volume-title":"Nursing Practice: The Ethical Issues","author":"Jameton Andrew","year":"1984"},{"key":"bibr20-00221465241254390","doi-asserted-by":"publisher","DOI":"10.1016\/j.jpainsymman.2015.11.009"},{"key":"bibr21-00221465241254390","doi-asserted-by":"publisher","DOI":"10.1200\/JOP.000129"},{"key":"bibr22-00221465241254390","doi-asserted-by":"publisher","DOI":"10.1016\/j.socscimed.2021.113676"},{"key":"bibr23-00221465241254390","unstructured":"Kaiser Family Foundation. 2023. \u201cKey Facts on Health Coverage of Immigrants.\u201d https:\/\/www.kff.org\/racial-equity-and-health-policy\/fact-sheet\/key-facts-on-health-coverage-of-immigrants\/."},{"key":"bibr24-00221465241254390","unstructured":"Keith Katie. 2023. \u201cHHS Issues Guidance to Help Protect Transgender Youth.\u201d Health Affairs, Blog. 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