International Journal of Intercultural Relations 82 (2021) 135–144 Contents lists available at ScienceDirect International Journal of Intercultural Relations journal homepage: www.elsevier.com/locate/ijintrel Framing inclusion: The media treatment of irregular immigrants’ right to health care in Spain Alisa Petroff a, *, 1, Anahí Viladrich b, Sònia Parella c a Universitat Oberta de Catalunya, Internet Interdisciplinary Institute, Parc Mediterrani de la Tecnologia (Edifici B3) Av. Carl Friedrich Gauss, Castelldefels (Barcelona), 5 08860, Spain b Queens College, The Graduate Center and The Graduate School of Public Health & Health Policy, The City University of New York (CUNY), 65-30 Kissena Blvd., New York City, NY 11367-1597, USA c Universitat Autònoma de Barcelona, Facultat CC. Polítiques i de Sociologia Departament de Sociologia, B3-179, Bellaterra (Cerdanyola del Vallès), 08193, Spain A R T I C L E I N F O A B S T R A C T Keywords: With the passing of Royal Decree-Law 16/2012, Spain’s national health system switched from a Health policy model defined by universal and free health care principles, to a private insurance system that Health Reform excluded large population groups. Based on a qualitative research design, this paper examines the Migration and health media treatment of undocumented immigrants’ prerogatives to public health care in Spain Spain Undocumented migrants (2012–2018). The analysis of 234 articles, drawn from three major Spanish newspapers, reveals three frames that underscore the media’s "rhetorics of inclusion," which argue for the extension of free medical services to irregular immigrantsa topic traditionally underestimated by the litera­ ture. The moralist frame, supported by social justice arguments, is found in tandem with the cost- benefit frame that advocates for immigrants’ health care access as a means for containing medical expenses. The overall predominance of the legalist frame largely relies on arguments that reflect a Spanish political culture rooted in the universality of health rights. Introduction Spain, a nation-state known for its comprehensive welfare system surprised the world when, on April 20, 2012, did a one hundred and eighty degrees turnaround in its health policy. Up until then—and for over thirty years—Spain’s national health system had guaranteed access to free and efficient health care to anyone residing within its territory, regardless of nationality, administrative status, or financial means. With the stroke of a pen, these values, grounded in universal health principles, were abruptly scrapped with the passing of the Royal Decree-Law 16/2012 (RD-L). Promulgated by the ruling Partido Popular (PP), the RD-L sanctioned a restrictive model of health care access, putatively aimed at reducing public health expenditures by switching to a market-based insurance model (Royo-Bordonada, Díez-Cornell, & Llorente, 2013). During those years, Spain transformed itself from a country that had one of the most inclusive health care systems in the world to one with the most onerous restrictions, particularly for the undocumented * Corresponding author. E-mail addresses: apetroff@uoc.edu (A. Petroff), anahi.viladrich@qc.cuny.edu (A. Viladrich), Sonia.Parella@uab.cat (S. Parella). 1 Collaborator of CER-Migracions (UAB). https://doi.org/10.1016/j.ijintrel.2021.03.004 Received 1 December 2020; Accepted 7 March 2021 Available online 8 April 2021 0147-1767/© 2021 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). A. Petroff et al. International Journal of Intercultural Relations 82 (2021) 135–144 immigrant population (Suess, Ruiz Pérez, Ruiz Azarola, & March Cerdà, 2014).2 In June 2018, Spain experienced a sudden political change, marked by the rise of a socialist government that quickly restored the universality of its health system; however, much of the debate about immigrants’ rights to health care have persisted since then. Before, during and after the passage of the RD-L, stances over curtailing health care services to immigrants were informed by discussions around Spain’s austerity policies and draconian financial cuts that had been in effect since the early 2000s (Boso & Vancea, 2016; Legido-Quigley et al., 2013). Despite the increasing interest in the health problems involving the immigrant population in Spain (Jansà & García de Olalla, 2004; Porthé et al., 2017; Salas-Coronas et al., 2018), little is known on the role of the Spanish media supporting ideological positions that argue for, both in favour and against, the health care provision—and extension of health rights— to the foreign-born population. In order to fill this gap, this study analysed a selection of news articles drawn from three major Spanish newspapers (El País, ABC, and El Diario.es) from 2012, when the Reform was implemented, to its subsequent derogation in 2018. Through the lens of framing theory, we examine the ideological underpinnings involved in the production and articulation of media arguments by posing the following questions: What are the main media frames for supporting the inclusion of unauthorized immigrants in the Spanish government’s health-care safety net, after the passage of RD-L in 2012? How does the media articulate the legal arguments that support the health care inclusion of the irregular foreign-born in Spain? What immigrant groups have been depicted as being the most entitled to inclusion into the Spanish public health system? This research paper utilizes the term "rhetorics of inclusion" to refer to the arguments, scripts, and representations that support the right to health care by the undocumented immigrant population in Spain. Findings from this study build upon recent literature documenting a switch in media framing concerning the irregular foreign-born, from criminal and deviant to humanizing perspectives that underline the need to protect the most vulnerable (Viladrich, 2019; Kim, Carvalho, Davis, & Mullins, 2011; Pourat, Wallace, Hadler, & Ponce, 2014; Stimpson, Wilson, & Su, 2013). We argue that, in the Spanish case, pro-immigrant frames—mostly represented by legal arguments— have been instrumental for voicing the demands of both civil society and political actors in support of the restoration of irregular immigrants’ health benefits after the passing of RD-L. We begin with a literature review of media framing on migration. A historical overview of the Spanish health care system will then be introduced, along with the political conditions leading to the RD-L. The third section presents the research design and methods, followed by the results section that hinges on the analysis of three media frames: the legalist frame, the moralist frame, and the cost- saving frame. In the conclusions, this paper sheds light on the prevalence of the legalist frame, both as a rhetorical tool advocating for the health care inclusion of undocumented immigrants and as a reflection of a Spanish political culture rooted in the universality of health rights. Framing the "Immigration Issue": a literature review The term "frame" in this study refers to semiotic constructs that stress specific characteristics according to their presumed negative and positive qualities (Viladrich, 2019; Goffman, 1974) infused with moral and emotional interpretations of phenomena (Entman, 1993). Media framing offers a conceptual lens through which to understand how the media constructs an issue as "a problem" while providing a cohesive semantic package to interpret its causes and consequences. Although the presumed causal relationships between public opinion and political agendas on immigration are not entirely un­ derstood, most authors agree on their reciprocal relationship (Viladrich, 2019; Haynes, Merolla, & Ramakrishnan, 2016; Montes, 2012). Media frames are much more than rhetorical devices: they are discursive instruments that influence the direction of public policy either in favor or against immigrants’ rights. The power of the media also involves a complex agenda-setting process in which the contents and direction of the frames are negotiated with main political stakeholders (Newton, 2009; Van Dijk, 2015). When it comes to immigration topics, the media prompts audiences to align with a specific vision on controversial issues, as when supporting a humanitarian frame (e.g., immigrants deserve compassion) or a threat stand (e.g., immigrants are dangerous subjects) (Vilarich, 2012; Santamaría, 2002). Therefore, against the ubiquitous backdrop of the faceless irregular immigrant who, in the developed world, is often described as a rule-breaker and job-stealer, the media selectively portrays immigrant groups either positively or negatively. In line with these dualities, the media’s reliance on humanitarian and compassionate frames is encouraged by ste­ reotypes of immigrants as sufferers—particularly undocumented mothers and their children (Amores & Arcila, 2019; Román, García, & Álvarez, 2011). "Moralizing frames" also underscore a generous view towards foreigners, particularly among those fleeing wars and political violence (Triandafyllidou, 2018). For instance, sympathetic responses towards Syrian nationals tend to portray them as stranded and helpless—features heightened by images of child refugees (Fotopoulos & Kaimaklioti, 2016). The poignant photograph of Alan Kurdi lying dead on a Turkish beach became a striking symbol of the ongoing global shift towards supporting a compassionate frame (De Poli, Jakobsson, & Schüller, 2017; Klein & Amis, 2020). In this view, Cava, Parito, and Pira, 2018 utilize the term "the aesthetics of pity" to signal the ways through which the European media draws emotional narratives aimed at eliciting compassion towards the foreign-born while counteracting the image of the "other-foreigner." Common among media stories is a hyper-visible portrait of immigrants and refugees that renders their voices and personal ex­ periences invisible. Rather than being allowed to speak for themselves, immigrants’ stories are often conveyed by those who either advocate for their human rights or deem them to be threats to mainstream cultural values and economic security (Figenschou & 2 The terms irregular and undocumented immigrant/s are used interchangeably in this paper to refer to those individuals who either entered Spain without proper authorization or who overstayed their visas, and that currently lack legal authorization to remain in the country. 136 A. Petroff et al. International Journal of Intercultural Relations 82 (2021) 135–144 Thorbjørnsrud, 2015; Musarò & Parmiggiani, 2017; Smets & Bozdağ, 2018; Sosa, Quintana, & Castillo, 2019). Public sympathy for the plight of immigrants and refugees, however, does not necessarily imply that they are seen as deserving of rights nor suggest supportive stands towards progressive immigration Reform(Cheng, Igartua, Palacios, Acosta, & Palito, 2014; Fabregat, Medina-Bravo, & Meyers, 2019; Goździak, Main, & Suter, 2020). Furthermore, while some studies note that the framing of immigrants as victims could eventually lead to changes in public opinion while mitigating bias against them (De Poli et al., 2017), others argue that the "victim frame" does not necessarily foster positive attitudes towards immigrants or favorable policies on their behalf (Bos, Lecheler, Mewafi, & Vliegenthart, 2016). In fact, as the refugee crisis in Europe subsided, from 2016 on, the media began abandoning humanitarian stands in favor of narratives that portrayed refugees as security and economic threats (Chouliaraki, Georgiou, Zaborowski, & Oomen, 2017; Heidenreich, Lind, Eberl, & Boomgaarden, 2019; Matar, 2017). The centrality of the immigration issue in Spain in recent years has been characterized by the correlation between the large influx of immigrants and their negative media images. Several groups (Latin Americans, African or Chinese immigrants) have been viewed as both a threat to Spanish cultural values and as economic competitors (Donovan, 2017; Otero García, 2011). Nevertheless, theseimages have been recently nuanced by the presence of a humanizing frame in the Spanish press, as seen by the recent positive reporting of the European refugee crisis (Montagut & Moragas-Fernández, 2020). Still, there has been little research on the media’s progressive views towards irregular immigrants in Europe generally and in Spain particularly. The analysis of such media narratives, during a period of significant shifts in health policy in Spain, will be the bulk of this paper’s data analysis. We now turn to discussing the historical and political conditions that led to profound transformations in the Spanish health care system and the eventual passing of the RD-L in 2012. Health care in transition in Spain The Spanish Constitution, passed in 1978, ruled health care as an inalienable right and (in its articles 41 and 43) it stipulated the creation of a National Health System (NHS) financed by an income tax on Spanish citizens. Born during a political transition, the end of the Franco dictatorship, and the beginning of democracy, this health care model guaranteed free and universal health coverage (Arango, 2013; Vázquez et al., 2016). In the following decades, Law 4/2000 consolidated this universal system. It also cemented immigrants’ right to health care (Lema Añón, 2014) by expanding health care coverage to the overall population, independently of their legal, administrative, or economic status. Considered unique in the world (Arango, 2013), the Spanish universal system made no distinction between regular and irregular immigrants and offered equal access to medical services to anyone residing on Spanish soil (Lema Añón, 2014). The RD-L broke the country’s long-standing social contract with its residents by creating uneven solutions to medical care while deepening health inequalities (Red Acoge, 2015). In the aftermath of its passing, most of the undocumented population in Spain—except for asylum seekers and trafficking victims— lost their health cards (Foro para la Integración Social de los Inmigrantes, 2011; Lema Añón, 2014). Still, undocumented immigrants remained eligible for emergency and maternal care as well as child­ care—the latter guaranteed to youth below the age of eighteen. Although the ruling party (PP) justified the Reform as an urgent measure to curb "health tourism"3 and reduce the public deficit, the RD-L severely impacted immigrant communities at a time when they were suffering the worst effects of the economic crisis (Cimas et al., 2016; Peralta-Gallego, Gené-Badia, & Gallo, 2018). The RD-L exacerbated the existing logistic, bureaucratic, and language barriers (Triviño, Rodríguez-Arias, & Ausín, 2016; Vázquez et al., 2016) and deepened regional differences in health entitlement for irregular immigrants (Gea-Sánchez et al., 2017). By linking health care access to employment contributions, only those active in the official labor force became beneficiaries of the NHS (Roy­ o-Bordonada et al., 2013). Government-based insurance programs were created as an alternative way to protect the uninsured. However, their costs (59 euros per month, more than most private medical insurance premiums) left almost 500,000 immigrants without health insurance (Legido-Quigley et al., 2013).4 As has been the case in the U.S. (Marrow, 2012), Spain’s NHS is highly decentralized and rests on a patchwork system of safety-net providers that leaves room for "grey zones" (Dobbs et al., 2018); the latter leading to policy discordances between national and local governments. Consequently, the application of the RD-L became highly heterogeneous at the regional level, leading to controversial management of health clauses in the autonomous communities (Vázquez et al., 2016). As a result, several Spanish regions either vetoed the policy altogether or applied it partially (Peralta-Gallego et al., 2018) depending on their respective ruling political parties at that time. While, in some cases, regional governments (ruled by opposition parties) allowed a partial or full health care inclusion by creating ad hoc protocols (Vázquez et al., 2016); others regions (ruled by the PP) strictly applied the Reform and thus exacerbated immigrants’ health care exclusion (Cimas et al., 2016). Finally, the sudden change of government in June 2018, after an allegedly scandalous case of corruption involving the ruling PP, marked the rise of a socialist government (PSOE) that almost immediately repealed the 2012 RD-L and restored the universality to the Spanish health model—at least on paper. As will be further discussed in this research piece, a key finding in this study rests on the consensus, among different civic orga­ nizations and political actors, against the RD-L. We will show how public debates concerning the inclusion of irregular immigrants into the NHS were extensively covered by the Spanish media, with articles questioning the RD-L and its deleterious effect on irregular immigrants. 3 Health tourism is usually defined as travelers intending to visit foreign countries for the main purpose of receiving high quality or cheaper/free health care services. 4 Some NGOs claim that the RD-L drove more than 800,000 people out of the system. 137 A. Petroff et al. International Journal of Intercultural Relations 82 (2021) 135–144 Methodology This project’s research design was based on the analysis of three main Spanish newspapers of record (El País, El Diario.es, and ABC), which were selected for three main reasons. First, newspapers with a large circulation tend to be "framers" of news that are referenced and republished by other media outlets (Viladrich, 2019; Grimm & Andsager, 2011). Second, in today’s Spain, more people get their news from print, online media, and TV than from social media platforms (Madrid Press Association, 2019). Finally, the lion’s share of recent studies on media framing has relied on mainstream Spanish newspapers (such as the ones chosen here) as their primary sources (Checa & Arjona, 2011; Pavia & Solá, 2017; Rodríguez Díaz & Mena Montes, 2008) During the initial data-collection phase, we exhaustively mapped articles addressing the RD-L and their implications for immigrant health. We narrowed the search to those published between April 2012 (when the RD-L was passed) and December 2018, when the Socialist coalition won the parliamentarian majority. We obtained subscriptions to the respective newspapers’ webpages in order to access articles published during the selected period. The following boolean terms were used, in alphabetical order: "Eastern European migrants," "Europe," "health care," "health Reform," "immigrants," "irregular," "Latino-American migrants," "migrants," "Royal Decree- Law 16/2012," "Spain," "Sub-Saharan migrants," and "undocumented migrants." The initial sample gathered 300 articles (67 published by ABC, 83 by El Diario.es, 150 by El País). After a first read, we excluded 66 articles that were mainly press-notes briefly describing the RD-L without any references to immigration issues. As a result, the final sample consisted of 234 articles. Data from each article was entered into a Microsoft Excel spreadsheet containing the following information 1) date of publication; 2) title of the article; 3) section; 4) the main expressions and phrases leading to the constructions of frames; 5) the enunciating subject (i.e., actors framing the topic, such as doctors, lawyers, immigrants themselves, etc.) and the target population (i.e., sick immigrants, unaccompanied minors, etc.). The study was based on content analysis of the selected articles aimed at identifying the main dimensions and arguments sup­ porting the frames, a technique known as frame mapping (Vilarich, 2012; Miller & Riechert, 2001). Following a constructivist content analysis, and supported by grounded theory, the articles were read multiple times in order to identify themes and common issues (Glaser & Strauss, 2017). Two of the authors carefully read the final sample of articles with a view toward identifying the most prevalent frames: those that were central in defining and building upon the argument’s main topics. The analysis was conducted manually by recording quotations and inferring specific frames that were then entered into the spreadsheet.5 The coders’ initial results were contrasted with each other towards ensuring comparable definitions, and related dimensions, of each frame. Hence, we extracted frames found to be intrinsically involved with the impact of the RD-L on immigrants’ entitlement to health care in Spain, as presented in the next section. Study results: media frames in support of immigrants’ right to health care Almost half of the media corpus included articles from El País (49 %), 29 % of the articles were from El Diario.es, and 22 % were from ABC. A significant number of articles (113) were published in 2012 when the RD-L was passed. Most of them were found in the "society section" of the newspaper (111 articles, representing 37 % of the overall corpus), reflecting the broad societal interest in health-related contents (Peláez Valdivieso, 2011); followed by the regional section (83 articles, 28 % of the total corpus). The latter mirrors the fact that a considerable number of articles deal with the application of the Reform by the autonomous communities—a phenomenon explained by the predominance of the subnational level in Spain (Dobbs et al., 2018). While in the case of ABC and El País, a majority of the articles appeared in the society section, and most of those published by El Diario.es were editorials. The latter reinforces El Diario.es’ support for independent and critical reporting of the negative impact of the RD-L on the immigrant population. The analysis of the overall sample (N = 234) reveals three predominant frames that support the inclusion of irregular immigrants into the NHS along with the elimination of the RD-L (Table 1). The first one, the "legalist frame," is defined by a set of arguments involving legal clauses, starting with the constitutional mandate that dictates equal access to health care to all individuals residing in Spain. The "moralistic frame" relies on interviews with actors that reject the RD-L on the basis of moral, ethical, and humanitarian arguments. Finally, the cost-benefit frame involves three clauses supporting the NHS’s coverage of irregular immigrants on the basis of: a) mid- and long-term economic and social benefits; b) savings in emergency care resulting from prevention and early detection of disease; and c) broader social returns such as the general population’s improved health and well-being (Robertson, Skelly, & Phillips, 2019). Table 1 presents the operationalized dimensions of the three frames identified in this study, and Table 2 introduces the main enunciating actors along with the target population for each frame. Three dimensions are found under the "legalist frame." First, international law experts define health care as a human right. This principle is scaffolded along a set of arguments that deem the Reform unconstitutional as it violates the principle of universality, expressly mandated by the Spanish Constitution. Second, the unequal implementation of the Reform across Spanish regions exposes arbitrariness in the access to health care among irregular immigrants. This argument condemns the harmful consequences of the RD-L mainly when undocumented immigrants were illegally denied treatment (i.e., emergency room services, pregnant/nursing mothers). The "moralist frame" encompasses five dimensions. The first one is supported by Christian values that are translated into compassion and charity towards the needy. Church figures, missionaries, and religious organizations are among the actors advocating 5 Table 1 (see Results’ section) presents the operationalized dimensions according to the identified arguments. 138 A. Petroff et al. International Journal of Intercultural Relations 82 (2021) 135–144 Table 1 Operationalization of Frames. Frames Legalist Moralist Cost-Benefit Health as a human right Christian values The risks for public health increase if undocumented Unconstitutional nature of the Reform Deontological code migrants do not receive timely medical care Prevention and follow-up of chronic disease is less Putting a human face: migrants as victims expensive in the long term Dimensions The Reform is discriminatory and racist Avoids overtaxing emergency rooms Inaccuracies of the RD-L that allow Lack of reliable governmental data on the presumable arbitrariness and confusion in practice Repaying migrants who previously cost-saving effects of the Reform contributed to the Spanish economy Migrants are not health tourists and are less prone to get sick Source: Authors’ data. Table 2 Main actors according to the three frames. Enunciating actors Target population Legalist •Superior Courts of Autonomous Communities Undocumented immigrants •Legal experts and scientists •International human rights organizations Moralist •Church authorities and religious members Vulnerable groups (i.e., women, children, older immigrants) •Health professionals •National and International organizations •NGOs •Migrants •Politicians Cost-benefit •Economists Overall population •Trade Unions •Health associations (infectious diseases, AIDS) •Politicians Source: Authors’ data. for the inclusion of undocumented immigrants into the NHS. In the same vein, we identified a set of arguments linked to the concept of duty sworn to by Spanish health professionals, in which conscientious objectors would treat all those in need of medical care­ —regardless of their legal status. A third dimension includes vulnerable migrant groups mostly portrayed as victims (e.g., children, single mothers, and asylum seekers) which, together, represent the primary target population of this frame. Their testimonies expose dramatic situations in which the application of the RD-L resulted in avoidable deaths. Diverse actors, including politicians or representatives of organizations (such as Médecins du Monde or the Universal Right to Health Observatory)highlight the cruel and xenophobic nature of the decree. Their arguments report the extent to which the Reform encouraged discriminatory stands against undocumented immigrants, along with the deepening of existing social inequalities across different communities. Finally, the need to repay the substantial contributions of immigrants appeals to a particular case of reciprocal solidarity. According to this argument, it would be morally and ethically unacceptable to deny medical services to vulnerable im­ migrants who have already contributed to Spain’s economic growth. Finally, the "cost-benefit" frame emphasizes the negative implications—in economic and social terms—of having a health system that excludes undocumented immigrants. It presents arguments that contradict the supposed savings in health spending, as claimed by the supporters of the RD-L. Within this frame, the first argument refers to the risks and costs for public health of excluding irregular migrants from the NHS. For instance, undocumented migrants suffering from infectious diseases might not be able to afford costly medical treatments. If their avoidable infections were to spread to the overall population, the government expenditures might be higher than the cost of providing free medical treatment to everyone from the very beginning. The second dimension, mostly supported by health experts, argues for investing in preventive measures as well as for the early medical treatment of chronic conditions, such as cancer or diabetes. Lack of health insurance could lead immigrants to postpone care, Table 3 Frequency Distribution of Frames. Frames Legalist Moralist Cost-Benefit Total frames Total articles El Diario.es 66 (41.5 %) 37 (31.9 %) 28 (30.8 %) 131 (35.8 %) 73 (31.2 %) ABC 25 (15.7 %) 26 (22.4 %) 16 (17.7 %) 67 (18.3 %) 40 (17.1 %) El País 68 (42.8 %) 53 (45.7 %) 47 (51.6 %) 168 (45.9 %) 121 (51.7 %) Total 159 (100 %) 116 (100 %) 91 (100 %) 366 (100 %) 234 (100 %) Source: Authors’ data. 139 A. Petroff et al. International Journal of Intercultural Relations 82 (2021) 135–144 ultimately resulting in higher medical expenses and the potential collapse of local health services in the long run (third dimension). A fourth argument, mostly pointed out by economic experts, involves the lack of both scientific data and governmental reports demonstrating the efficiency of the RD-L in terms of reducing public spending on health care. The final dimension refutes the connection between immigration and health tourism— one of the main arguments used by the government to implement the Reform in the first place. In our media corpus, this was contested by data showing that immigrants are neither health tourists nor more prone to getting sick than the native-born population. Finally, this frame targets the overall population in agreement with the NHS’s universal coverage principles. Table 3 summarizes the frequency distribution of the three frames among the three newspapers. A total of 366 frames appear in the 234 articles analysed, reflecting the fact that several frames were presented jointly. Almost four out of ten articles belong to eldiario.es and El País, respectively. The moralist frame was identified in 116 articles, 45.7 % from El País. The cost-benefit frame was the least relevant in our corpus, appearing in 91 out of 234 articles. Half of the arguments linked to the cost-benefit frame were found in El País. The significant weight of the cost-benefit and moralist frames in the articles from El País could be explained by its ideological shift from 2012 onwards—when it featured a more liberal and centre-right approach (Público, 2014). Now we turn to a detailed analysis of the legalist frame, the one that appears the most in our media corpus. The legalist frame: universality and free access to health care From the overall sample (N = 234), 159 articles (67.9 %) present at least one legalist argument. Table 4 displays the frequency distribution of the main dimensions comprising this frame, taking into account that more than one dimension may be used for strengthening the frame. We now turn to analyse each of them. Health care as a human right From the 159 articles supporting the legalist frame, the reference to health care as a human right appears in 24, and almost 6 out of 10 in eldiario.es. A representative of a left-wing opposition party (Podemos) asserted that the Reform is "a medical apartheid and a systematic violation of human rights. It is a step further towards a selfish Europe, which does not recognize fundamental rights." (eldiario.es 03/10/2015). For experts in international law, denying health care access to irregular immigrants means ignoring the international treaties signed by Spain. Specific mentions to Article 25 of the Universal Declaration of Human Rights (Geneva, 1948) are meant to remind Spain that every human being has the right to basic health care and social services. According to the director of the Institute for the Right to Universal Health Care (eldiario.es 12/20/2017), the PP government ignored the recommendations of international human rights or­ ganizations, which argue for providing health care to all individuals. Those organizations considered the RD-L to be a regressive and unethical measure. The United Nations and Amnesty International pointed out that, with the passing of the RD-L, the Spanish gov­ ernment failed to comply with its commitments to international law. The fact that undocumented immigrants were denied medical treatment at Spanish public hospitals is clear evidence that their human rights were violated. International treaties, signed by Spain, complete this vision of health as a human right. This is the argument introduced yesterday by the bar association against the RD-L, which restricts medical coverage to irregular immigrants. (El País 04/30/ 2012) The United Nations considers the health care Reform in Spain unacceptable, as it conflicts with the international obligations of Spain with the people residing in its territory, regardless of their legal status. (eldiario.es 05/11/2014) Other articles reported how hospitals issued bills to undocumented immigrants that had already been treated for severe illnesses. Representatives from Amnesty International argued that these practices should stop immediately and "reminded health authorities that regulatory compliance and respect for human rights should not depend on the presence or not of civil society organizations." (eldiario.es 04/21/2015). Despite the efforts of international organizations to restore the universality of health care based on human rights ar­ guments, several articles point out that the Spanish national government repeatedly ignored them. These arguments were later utilized by the ruling socialist party to support the restoration of universal health care in 2018. Unconstitutional nature of the reform The unconstitutionality of the Reform is one of the main principles deployed by the media in support of the legalist frame. Ar­ guments advocating for health care access, as a universal right guaranteed by the Constitution, appear in 76 out of 159 articles representing the legalist frame (Table 3). Specifically, four out of ten articles are present in eldiario.es and El País. The fact that the NHS provides free, accessible and equitable health care is portrayed as an irreversible achievement of the democratic transition backed by stakeholders, representatives of trade unions, and NGOs. For them, the Reform symbolized a step backward, since the ongoing pri­ vatization of medical services places irregular migrants in a situation of extreme vulnerability. Among other things, the decree eliminates the universalist nature of the access, changing the concept of the person as a rights holder to that of the insured, expelling thousands of people from the system. With the new regulations, we consider that two constitutional precepts are being violated: Article 43, which recognizes the right to health protection and Article 9.2, which regulates the role of public powers as guarantors of this right. (El País 06/22/12) Several autonomous communities (Andalusia, Asturias, Catalonia, the Canary Islands, the Basque Country, the Balearic Islands, and Valencia, among others) took a political stand against the RD-L and announced that they would guarantee health care to undocu­ mented migrants in their territories. Henceforth, not only did they refuse to apply the general Reform but also its subsidiary clauses (e. 140 A. Petroff et al. International Journal of Intercultural Relations 82 (2021) 135–144 Table 4 Frequency distribution of the dimensions belonging to the legalist frame. Legalist frame Health as a human right Unconstitutional nature of the Reform Inaccuracies and arbitrariness in the practice Total legalist frame El Diario.es 14 (58.3 %) 31 (40.8 %) 41 (56.9 %) 66 (41.5 %) ABC 2 (8.4 %) 12 (15.8 %) 7 (9.8) 25 (15.7 %) El País 8 (33.3 %) 33 (43.4 %) 24 (33.3 %) 68 (42.8 %) Total 24 (100 %) 76 (100 %) 72 (100 %) 159 (100 %) Source: Authors’ data. g., a co-payment of drugs and other health benefits). The Andalusian Government entirely opposed the exclusion of undocumented migrants and continued to provide health care to those who lack financial resources and health insurance. This right, which has been guaranteed since 1999, is a decision based on solidarity that tries to protect the most vulnerable population (ABC, 08/27/2015) As broadly covered by the media, these regions initially threatened to appeal the Reform to the Constitutional Court and eventually sued the central government on the basis of the RD-L’s alleged unconstitutionality. Among others, the Balearic Islands won the trial with the court’s decision concluding the following: According to the ruling of the Superior Court of Justice, the Reform was a "clear overreach of jurisdiction" in the trial and "a clear violation of the principle of regulatory hierarchy." (ABC, 09/08/2017). The Constitutional Court has annulled the suspension of the Navarra Law on Health Care—claimed by the Central Gov­ ernment—which provides complete health care to immigrants who lost their health card due to the RD-L. In its text, the ar­ guments of the high court are of particular importance given the claims of unconstitutionality against the decree that have been argued by several autonomous communities. (eldiario.es, 04/16/2014) Inaccuracies and arbitrariness in health care practice The last dimension of the legalist frame appears in 72 articles, most often in eldiario.es (see Table 3). Immediately after the passing of the RD-L Reform, health professionals reported a lack of information—as well as confusion—regarding the measures to be taken by regional governments to counteract the Reform’s harmful effect. For instance, the Vice President of the Madrid Society for Family and Community Medicine, Vicente Baos, argued: This is nonsense…They make significant changes, and the precise instructions don’t reach anyone. We are against the Royal Decree, but at least the government could clarify the main criteria used. This shows great improvisation on their part (El País, 07/29/2012) Given the unequal application of the RD-L at the regional level, different civic platforms in support of universal health care reported arbitrary practices in several territories—a phenomenon that exacerbated the puzzling application of the law’s health care clauses even more. A spokesman for the Yo Sí, a pro-inclusion civic platform, made the following point: Two years after the RD-L came into effect, health-care centres continue to be poorly notified about the regulations. Irregularities occur systematically on a daily basis. (eldiario.es 07/15/2014) Other practices involved financial abuse as in the case of hospitals requiring irregular migrants to pay for emergency care. This was noted as contrary to the spirit of the RD-L, which purportedly guaranteed free urgent medical services to anyone who needed it. Therefore, employees from Madrid Primary Care Centres and members of the Yo Sí, platform reported the presence of "wild arbi­ trariness and confusion" concerning the provision of health care by public health centres (eldiario.es 11/10/2014). One of the articles quoted a report by REDER6 that denounced 541 situations of health exclusion only in the first year after the Reform was passed. The same article mentions previous studies that had identified more than 1,500 similar cases. REDER criticizes the fact that the scenario is very heterogeneous and that rights concerning a central area such as health varies depending on where you live. Some cases involve illegalities. For example, those affecting minors (36); 47 incidents in the emergency room (many attempts to bill patients); 28 cases of pregnant women who could not access treatment and follow-up of their pregnancy (eldiario.es 04/20/2016) In the final section, we examine the main contributions of the study along with the extent to which Spain’s mainstream political culture, in support of the universal access to health care, has been propelled—and influenced by—the media frames discussed in previous pages. Conclusions While a significant bulk of the literature (Fabregat et al., 2019; Figenschou & Thorbjørnsrud, 2015; Musarò & Parmiggiani, 2017; Smets & Bozdağ, 2018; Sosa et al., 2019) has highlighted the negative images of immigration depicted by media, this paper has filled a vacuum by analysing the main media frames that support the inclusion of irregular immigrants into the Spanish public health system. 6 Network of Denunciation and Resistance [against the RD-L]. (REDER-Red de Denuncia y Resistencia). 141 A. Petroff et al. International Journal of Intercultural Relations 82 (2021) 135–144 Based on the analysis of a sample of articles drawn from three major Spanish newspapers (2012-18) this study has revealed three main media frames that underscore the media’s "rhetorics of inclusion." In line with the literature (Viladrich, 2019; Triandafyllidou, 2018), our findings highlight the presence of the "moralist frame" on the basis of social-justice stands. First, the hyper-visibility of immigrants portrayed as sufferers (mainly based on testimonies of vulnerable immigrants) was not the only argument used to shape this frame. In fact, humanitarian stands on behalf of ailed irregular immigrants were found in conjunction with arguments appealing to moral obligations and ethical values, which somehow dilute what Cava et al., 2018 call "the aesthetics of pity". Second, the moralist frame was found in tandem with the "cost-benefit frame" that supports the extension of health benefits to all immigrants as a means of containing health care costs, as has been shown by related research in the USA (Vilarich, 2012). To a certain extent, these research findings transcend the health care field and unveil the media’s positive views towards irregular migrants in Europe, generally, and in Spain, particularly. Hence, one of the main contributions of this study points out to the prominence of the "legalist frame," both in qualitative and quantitative terms, a finding that can be explained by historical and political processes that profoundly transformed the Spanish society in recent decades. The transition to democracy in 1978 legally reformed the Spanish NHS by quickly turning it into a universal and accessible health care model. Moreover, the large influx of immigrants, from 2000 onwards, became politically and administratively managed through the lens of an inclusionary paradigm of immigrant inte­ gration (Cebolla Boado & González Ferrer, 2013; Red Acoge, 2015). In fact, the arguments supporting the legalist frame, as discussed in this paper, are found to be in agreement with such paradigm. Although Spain was one of the European countries hit hardest by the economic crisis (post-2008), it did not experience the sweeping wave of anti-immigrant sentiments that many other nations in the continent did (Arango, 2013). According to Arango, 2013:10, the contemporary political culture of Spain was built through an idealization of values associated with the full recovery of democracy, based on equal and universalistic values. This assessment generated a tacit, but powerful, consensus in Spanish society regarding the universal access to fundamental social rights (i.e., health or education), regardless of legal or financial status of the beneficiaries. The social and historical processes presented above clearly account for the prevalence of the "rhetorics of inclusion" in our media sample and, particularly, for the significant weight of the legalist frame over the moralistic and cost-saving frames. Contrary to compassionate views of irregular immigrants who are often pitied on the basis of humanitarian claims (Cheng et al., 2014; Fabregat et al., 2019) our findings reveal the Spanish public’s sympathy for irregular immigrants, mostly deemed as legitimate recipients of medical care. Furthermore, by mostly focusing on the legalist frame, the media underscores the role played by the Spanish political culture in support of the right to health care to all immigrants, regardless of their legal, administrative or economic status. The unquestionable nature of the right to health in Spain has been, in due course, translated into legal arguments, proposed by the media, that have been instrumental for voicing the demands of key actors (from civil society and political parties) in support of im­ migrants’ health rights. From this perspective, the legalist frame presented in this paper, both reflects and contributes to strengthening the public support for immigrants’ health care entitlements on the basis of their constitutional rights—arguments that would be eventually utilized to derogate the Reform in 2018. More research is needed for a better understanding of the heterogeneous application of the RD-L at the regional level, along with the media role in either reinforcing or counteracting such regional disparities. Although not the main focus of this paper, the diverse application of the RD-L among the autonomous communities points out to the complexity of Spain’s decentralized political system. As discussed previously, divergent health regulations at the regional level, greatly dependent on local politics, have often translated into the arbitrary provision of medical services to vulnerable groups—including irregular immigrants (Dobbs et al., 2018). Finally, pro­ spective work will replicate this analysis by addressing comparative case studies, including countries with similar decentralized po­ litical systems (i.e., USA) and European nations with large immigration flows (i.e., Germany and France). Acknowledgement We would like to thank the Catalan Studies Institute (2018-2019, Spain), and the Professional Staff Congress of the City University of New York (2019-20, USA), for their funding support. Previous versions of this paper were presented at events organized by the Spanish Congress of Sociology (Valencia, Spain, 2019), Latin American Studies-LASA (Barcelona 2018); the International Sociological Association (Toronto, Canada, 2018), the European Sociological Association (Athens, Greece 2017) and The Latin American Studies Association (Lima, Peru, 2017). We are also grateful for the constructive suggestions of Thomas Faist and of several anonymous re­ viewers, whose comments greatly contributed to improving the final version of this article. Finally, we thank Geraldo Sierra Soto for his participation during the elaboration of this research project’s database. References Amores, J. J., & Arcila, C. (2019). Deconstructing the symbolic visual frames of refugees and migrants in the main Western European media. Proceedings of the Seventh International Conference on Technological Ecosystems for Enhancing Multiculturality, 911–918. https://dl-acm-org.queens.ezproxy.cuny.edu/doi/pdf/10.1145/ 3362789.3362896. Arango, J. (2013). Exceptional in Europe? Spain’s experience with immigration and integration. Migration Policy Institute. Bos, L., Lecheler, S., Mewafi, M., & Vliegenthart, R. (2016). It’s the frame that matters: Immigrant integration and media framing effects in the Netherlands. International Journal of Intercultural Relations, 55, 97–108. Boso, A., & Vancea, M. (2016). Should irregular migrants have the right to health-care? Lessons learnt from the Spanish case. Critical Social Policy, 36(2), 225–245. Cava, A., Parito, M., & Pira, F. (2018). The aesthetics of pity. Italian media representation of migrants and emotional audience. ICSR Mediterranean Knowledge-Working Papers Series. Cebolla Boado, H., & González Ferrer, A. (2013). In A. Editorial (Ed.), Cómo se ha gestionado la inmigración en España. Madrid. 142 A. Petroff et al. International Journal of Intercultural Relations 82 (2021) 135–144 Checa, J. C., & Arjona, Á. (2011). Españoles ante la inmigración: el papel de los medios de comunicación. Comunicar, 19(37). Cheng, L., Igartua, J. J., Palacios, E., Acosta, T., & Palito, S. (2014). Framing immigration news in Spanish regional press. International Migration, 52(6), 197–215. http://www.redalyc.org/html/2050. Chouliaraki, L., Georgiou, M., Zaborowski, R., & Oomen, W. A. (2017). The European’ migration crisis’ and the media: A cross-European press content analysis. London: London School of Economics. Cimas, M., Gullon, P., Aguilera, E., Meyer, S., Freire, J. M., & Perez-Gomez, B. (2016). Health-care coverage for undocumented migrants in Spain: Regional differences after Royal Decree Law 16/2012. Health Policy, 120(4), 384–395. De Poli, S., Jakobsson, N., & Schüller, S. (2017). The drowning-refugee effect: Media salience and xenophobic attitudes. Applied Economics Letters, 24(16), 1167–1172. Dobbs, E., Levitt, P., Parella, S., & Petroff, A. (2018). Social welfare grey zones: how and why subnational actors provide when nations do not? Journal of Ethnic and Migration Studies, 1–18. Donovan, M. K. (2017). “Se ríen de la crisis”: Chinese Immigration as Economic Invasion in Spanish Film and Media. Revista de Estudios Hispánicos, 51(2), 369–393. Entman, R. M. (1993). Framing: Toward clarification of a fractured paradigm. The Journal of Communication, 43(4), 51–58. Fabregat, E., Medina-Bravo, P., & Meyers, M. (2019). Neighborhood Press and Immigration: A frame-building analysis of the depiction of immigrants. Journalism Practice, 13(5), 602–619. Figenschou, T. U., & Thorbjørnsrud, K. (2015). Faces of an invisible population human interest framing of irregular immigration news in the United States, France, and Norway. The American Behavioral Scientist, 59(7), 783–801. Foro para la Integración Social de los Inmigrantes. (2011). Informe sobre la situación de la integración social de los inmigrantes y refugiados en 2011. Madrid: Ministerio de Trabajo e Inmigración. Available at: http://www.foroinmigracion.es/es/MANDATO-FORO-2010-2015/Plenos/2011/docs/INFORME_ANUAL_FOR0_2011x2x.pdf Accessed on: May 2020. Fotopoulos, S., & Kaimaklioti, M. (2016). Media discourse on the refugee crisis: on what have the Greek, German and British press focused? European View, 15(2), 265–279. Gea-Sánchez, M., Alconada-Romero, Á, Briones-Vozmediano, E., Pastells, R., Gastaldo, D., & Molina, F. (2017). Undocumented immigrant women in Spain: a scoping review on access to and utilization of health and social services. Journal of Immigrant and Minority Health, 19(1), 194–204. Glaser, B. G., & Strauss, A. L. (2017). Discovery of grounded theory: Strategies for qualitative research. New York: Routledge. https://doi.org/10.4324/9780203793206. Goffman, E. (1974). Frame analysis: An essay on the organization of experience. Cambridge, MA: Harvard University Press. Goździak, E. M., Main, I., & Suter, B. (2020). Europe and the refugee response: A crisis of values? Routledge. Grimm, J., & Andsager, J. L. (2011). Framing immigration: Geo-ethnic context in California newspapers. Journalism & Mass Communication Quarterly, 88(4), 771–788. Haynes, C., Merolla, J., & Ramakrishnan, S. K. (2016). Framing immigrants: News coverage, public opinion, and policy. New York: Russell Sage Foundation. Heidenreich, T., Lind, F., Eberl, J. M., & Boomgaarden, H. G. (2019). Media framing dynamics of the’ European refugee crisis’: A comparative topic modelling approach. Journal of Refugee Studies, 32(Special_Issue_1), i172–i182. Jansà, J. M., & García de Olalla, P. (2004). Salud e inmigración: nuevas realidades y nuevos retos. Gaceta Sanitaria, 18, 207–213. Kim, S. H., Carvalho, J. P., Davis, A. G., & Mullins, A. M. (2011). The view of the border: News framing of the definition, causes, and solutions to illegal immigration. Mass Communication & Society, 14(3), 292–314. Klein, J., & Amis, J. M. (2020). The dynamics of framing: Image, emotion and the european migration crisis. The Academy of Management Journal (ja). Legido-Quigley, H., Otero, L., la Parra, D., Alvarez-Dardet, C., Martin-Moreno, J. M., & McKee, M. (2013). Will austerity cuts dismantle the Spanish health-care system? Lancet. Lema Añón, C. (2014). La titularidad del derecho a la salud en España: ¿hacia un C.ambio de modelo? Revista de Bioética y Derecho, (31), 3–16. Madrid Press Association. (2019). Informe Anual de la Profesión Periodística. Madrid: Ediciones Asociación de la Prensa de Madrid (APM). Marrow, H. B. (2012). Deserving to a point: Unauthorized immigrants in San Francisco’s universal access health-care model. Social Science & Medicine, 74(6), 846–854. Matar, D. (2017). Media coverage of the migration crisis in Europe: A confused and polarized narrative. IEMed Mediterranean Yearbook (pp. 292–295). Miller, M., & Riechert, B. P. (2001). Frame mapping: A quantitative method for investigating issues in the public sphere. Progress in Communication Sciences, 61–76. Montagut, M., & Moragas-Fernández, C. M. (2020). The european refugee crisis discourse in the spanish press: Mapping humanization and dehumanization frames through metaphors. International Journal of Communication, 14, 23. Montes, N. M. (2012). Immigration in Spain (2000-2008): Agenda setting and frame building. Madrid: Lambert Academic Publishing. Musarò, P., & Parmiggiani, P. (2017). Beyond black and white: The role of media in portraying and policing migration and asylum in Italy. International Review of Sociology, 27(2), 241–260. Newton, L. (2009). Illegal, alien, or immigrant: The politics of immigration reform. New York City: New York University Press. Otero García, L. (2011). Aproximación a las Representaciones Sociales Sobre la Salud de la Población Inmigrante en el Discurso Periodístico en la Prensa Escrita Española (2000-2006). Madrid: Instituto de Salud Carlos III. agosto de 2011. Pavia, C. F., & Solá, N. S. (2017). Comentarios sobre inmigración en tres periódicos en línea españoles: Aproximación a un discurso racista enmascarado. Revista Q, 10 (20), 137–156. Peláez Valdivieso, A. (2011). La salud y su manipulación. Análisis de dos periódicos nacionales: El País y El Mundo. Revista Española de Comunicación en Salud, 2(1), 13–23. Peralta-Gallego, L., Gené-Badia, J., & Gallo, P. (2018). Effects of undocumented immigrants exclusion from health care coverage in Spain. Health Policy, 122(11), 1155–1160. Porthé, V., Vargas, I., Ronda, E., Malmusi, D., Bosch, L., & Vázquez, M. L. (2017). Has the quality of health care for the immigrant population changed during the economic crisis in Catalonia (Spain)? Opinions of health professionals and immigrant users. Gaceta Sanitaria. Pourat, N., Wallace, S. P., Hadler, M. W., & Ponce, N. (2014). Assessing health care services used by California’s undocumented immigrant population in 2010. Health Affairs, 33(5), 840–847. Público. (2014). ’El País’ cambia de director y la redacción teme un giro a la derecha. https://www.publico.es/actualidad/pais-cambia-director-y-redaccion.html. Red Acoge. (2015). Los efectos de la exclusión sanitaria en las personas inmigrantes más vulnerables. Madrid: Red Acoge. http://redacoge.org/mm/file/2015/Jur%C3% ADdico/Informe%20Sanidad%20RED_ACOGE.pdf. Robertson, L., Skelly, C., & Phillips, D. (2019). Making hard choices in local public health spending with a cost-benefit analysis approach. Frontiers in Public Health, 7, 147. https://doi.org/10.3389/fpubh.2019.00147. Rodríguez Díaz, R., & Mena Montes, N. (2008). Opinión Pública y frames: La crisis de los cayucos. Revista Latina de Comunicación Social, 11(63). Román, M., García, A., & Álvarez, S. (2011). Tratamiento informativo de la mujer inmigrante en la prensa española. Cuadernos de información (p. 29). http://www. redalyc.org/html/971/97122694017/. Royo-Bordonada, MÁ, Díez-Cornell, M., & Llorente, J. M. (2013). Health-care access for migrants in Europe: The case of Spain. Lancet, 382(9890), 393–394. Salas-Coronas, J., Cabezas-Fernández, M. T., Lozano-Serrano, A. B., Soriano-Pérez, M. J., Vázquez-Villegas, J., & Cuenca-Gómez, JÁ. (2018). Newly arrived african migrants to Spain: Epidemiology and burden of disease. The American Journal of Tropical Medicine and Hygiene, 98(1), 319–325. Santamaría, E. (2002). Inmigración y barbarie. La construcción social y política del inmigrante como amenaza. Papers: Revista de Sociología, 66, 59–75. Smets, K., & Bozdağ, Ç. (2018). Editorial introduction. Representations of immigrants and refugees: News coverage, public opinion and media literacy. Communications, 43(3), 293–299. Sosa, A., Quintana, L., & Castillo, A. (2019). Humanitarian crisis and public opinion. Treatment of immigration in the Spanish media. Malaga. Spain: RIUMA. Stimpson, J. P., Wilson, F. A., & Su, D. (2013). Unauthorized immigrants spend less than other immigrants and US natives on health care. Health Affairs, 32(7), 1313–1318. Suess, A., Ruiz Pérez, I., Ruiz Azarola, A., & March Cerdà, J. C. (2014). The right of access to health care for undocumented migrants: A revision of comparative analysis in the European context. European Journal of Public Health, 24(5), 712–720. 143 A. Petroff et al. International Journal of Intercultural Relations 82 (2021) 135–144 Triandafyllidou, A. (2018). A "refugee crisis" unfolding: "real" events and their interpretation in media and political debates. Journal of Immigrant & Refugee Studies, 16 (1-2), 198–216. Triviño, R., Rodríguez-Arias, D., & Ausín, T. (2016). Exclusion from health-care in Spain: The responsibility for omission of due care. Ethical issues in poverty alleviation (pp. 191–205). Cham: Springer. Van Dijk, T. A. (2015). Racism and the press (Vol. 5). Routledge. Vázquez, M. L., Vargas, I., Jaramillo, D. L., Porthé, V., López-Fernández, L. A., Vargas, H., et al. (2016). Was access to health care easy for immigrants in Spain? The perspectives of health personnel in Catalonia and Andalusia. Health Policy, 120(4), 396–405. Vilarich, A. (2012). Beyond welfare reform: Reframing undocumented immigrants’ entitlement to health care in the United States. A critical review. Social Science & Medicine, 74, 822–829. Viladrich, A. (2019). We Cannot Let Them Die: Framing Compassion towards the Health Needs of Unauthorized Immigrants in the United States (U.S.). Qualitative Health Research, 29(10), 1447–1460. 144