The Role of Sub-National Governance in Global Social Protection: A Comparative Case Study of Spain and USA in Health Care

Much research on how migrant workers and their families get protected and provided for, sidesteps a key set of actors who can hold enormous sway over social policies affecting immigrants: sub-national and regional governments. Although immigration policy is largely the responsibility of the national government, in countries where political power is decentralized, sub-national governments go beyond their national counterparts in regulating social welfare provision to immigrants, either by restricting or extending it.

Using the theoretical framework of “resources environment” (Levitt at al, 2015) to analyze, and understand the transforming world of global social protections, this paper aims to bring into discussion the way receiving countries conceive the access of immigrants to health care. To begin understanding the extent to which sub-national governments can offset national policies concerning immigrants’ access to health care, this paper analyzes health care reforms in two immigrant receiving nations, Spain and the United States, with the focus on the tension between the state and the subnational governments: New York and California for the case of United States and the Autonomous Communities of Madrid and Andalucía for the Spanish case.

Both countries are among the most decentralized states and both have high levels of immigration (although Spain’s history as a major immigrant receiving country is fairly recent), with the challenge to manage undocumented immigration.  Nevertheless, they differ very strongly in the definition of universal health care coverage in historical terms and as regards the ranking in the world of their respective health care systems by the World Health Organization.

In this way, this paper shows 1) how two countries with different health care traditions conceive migrants access to health after the economic crisis and the implementation of the reform; 2) the extent to which sub-national governments, marked by left/right ideological perspectives, have scope in implementing the legislation.