Tiffany D. Joseph, "Not All In: Race, Immigration, and Health Care Exclusion in the Age of Obamacare" (Johns Hopkins UP, 2025)
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Welcome to the New Books Network. Hello, everyone, and welcome to the New Books Podcast. I'm Deidre Tyler-Holst, and today we'll be talking with Professor Tiffany D. Joseph, author of Not All In, Race, Immigration, and Healthcare Exclusion in the

in the age of Obamacare. How are you doing today, Professor? Hi, thank you so much for being here. I'm doing as well as I can under the circumstances with everything that's going on right now. Yes. I wonder if you could tell the audience a few words about yourself and how you got started on this project.

Yes. So I am an associate professor of sociology and international affairs at Northeastern University. And my research interests really look at a few things, issues of race and migration in the U.S., but also comparing how

to the U.S. sort of navigate race relations in the U.S., but also when they go back to their home countries, how that sort of shapes and transforms their perception of their lives and broader social structures and things like discrimination and what have you in their countries of origin. And

I've also done research looking at issues of health care access and really trying to understand the challenges that people face navigating our complicated health care system amid a range of policy reforms that have happened over the last 20 years or so.

And in terms of this particular project, the idea for it actually came to me when I was doing research for my first book, which is based on my dissertation. And in that project, I was looking at how immigrating to the U.S. changes how Brazilian immigrants think about race. And then after living in the U.S., when they go back to Brazil, how does living in the U.S. transform their understanding of race, racial categories and inequality in Brazil?

And I was doing that research in this really small town in the state of Minas Gerais, which has historically been the largest immigrant-sending city to the U.S. from Brazil. And in a number of my interviews with return migrants, these people who migrated to the U.S. and went back to Brazil, they were

The issue of health kept coming up in my interviews. So even though I wasn't directly asking about it because the focus of my process was more about people's understanding of race and racial categories, people kept talking about health without me prompting them. So some of the people I interviewed would say things like,

When I lived in the U.S., I couldn't get access to health care or I struggled trying to basically maintain my health because I was working really long hours. I wasn't getting much sleep. I wasn't eating very well. This started to have an impact on me. Some people talked about how...

When they lived in the U.S. and they were undocumented, they had employers that would exploit them and then threatened to basically report them to ICE if they didn't work really long hours or if they were underpaid and tried to basically say, hey, you need to pay me for the work that I did. And then a few of the people I interviewed even went so far as to say things like,

My health really started affecting me in the U.S. and I returned to Brazil because I thought I would have better access to health care in Brazil than in the U.S.

And that really stuck with me because all of those people kept bringing up the issues of health, either healthcare access challenges, either the impact of sort of the sort of high-paced way of living, lifestyle of living in the U.S. where you work long hours, you don't take care of yourself very well. And that really, really stuck with me. And so by the time that I finished that project and I finished graduate school, I got the opportunity to do what's called a postdoctoral fellowship.

which is basically two years after you finish your PhD and maybe before you start a faculty position. And I ended up getting this postdoc with the Robert Wood Johnson Foundation, which had a postdoc called the Health Policy Scholars Program. And I was based or placed at the site at Harvard University in 2011 to 2013. And at that time, um,

Basically, the Affordable Care Act had recently been signed into law under President Obama and the implementation process was getting ready to start sort of all of the pieces together for the ACA. And I thought, you know, this might be a really important moment to try to understand issues of health care access for immigrants today.

as this policy reform is about to be implemented and also being in greater Boston or in Cambridge, which is where comprehensive health reform had been already passed in the state in 2006. And it was really getting all of this national attention. And I was just really curious about if you're an immigrant living in the state of Massachusetts, can you benefit from this great reform that's getting all of this national attention and praise? And that was basically sort of the start of the project.

which became the basis for the research that I talk about in Not All In. So even though this research was conducted in Greater Boston, it actually started or the idea for it started thousands of miles away in Brazil. Excellent. Could you tell us about the population you studied and your research methods?

Yes. So I'll just first say when I started this project, I thought I was going to be doing research for maybe one year looking at this issue of the relationship between documentation status and healthcare access in greater Boston for different immigrant populations. And because

And because the policy context kept shifting so much over time, I continued to go back to greater Boston to continue to do research to try to understand the impact of those policy changes over time. At any rate, I really decided that I wanted to focus on policy.

immigrants from Latin America that are graced in greater Boston for a few reasons. First, a lot of the research that's been done in the U.S. on people of Latin American heritage or who identify as Latino or Hispanic, much of that work focuses primarily on individuals of Mexican heritage, with some studies also being on Puerto Ricans.

and some Central Americans. But we know a lot less about the experiences of South American immigrants in the U.S. and also some immigrants from the Caribbean, like Dominicans, for instance. And it just so happened that Greater Boston is a very, very diverse area with immigrants from everywhere. And three of the largest immigrant groups in Greater Boston happen to be from Brazil, the Dominican Republic, and El Salvador.

And for me, I thought it would be a really important opportunity to really try to understand how these differences in nationality, documentation status, but also how these groups are racialized in the U.S. would shape their experiences with the U.S. healthcare system.

Brazilian immigrants tend to be lighter in skin tone or racialized as white in the U.S. They come to the U.S. with tourist visas but overstay them and become undocumented. And they also tend to come from middle class backgrounds in Brazil before they migrate to the U.S.,

On the other hand, Dominican immigrants tend to come from lower income backgrounds. They're racialized as Black in the United States. And then many of them typically have green cards or they're legal permanent residents or naturalized citizenship.

And then lastly, Salvadorans tend to be somewhere between Brazilians and Dominicans in terms of physical features or what sociologists and others might refer to as racial phenotype. So typically people from El Salvador tend to have more of what are considered mestizo features or the physical features that people often think of when they hear the word Latino. So maybe medium brown skin tone, straight black hair, what have you.

And salvage or some of them are undocumented, but others are also eligible or have been eligible for this special documentation status called temporary protected status.

which is basically a documented status that allows work authorization in the U.S. and protection from deportation, but it does not provide a path to citizenship. And so oftentimes scholars have talked about temporary protected status as a precarious legal status for this population. And given that all three of these groups are in greater Boston, they have all these interesting sort of demographic characteristics, uh,

It really was an ideal group to really try to understand how a wide range or three different Latin American immigrant groups in greater Boston navigate the health care system and how their race, their ethnicity and their documentation status shape that access.

In terms of research methods, basically what I ended up doing over the course of the book, which I write about, is I interviewed over 200 people for this project across three different stakeholder groups. One of those groups, the most important one in terms of their insights, was the immigrant sample. And I already talked a little bit about those Brazilian, Dominican, and Salvadoran immigrants there.

I also interviewed healthcare providers that have immigrant patients in Greater Boston to try to understand how these different policy reforms in terms of the Massachusetts Health Reform and the Affordable Care Act reconfigured their ability to provide care for their immigrant patients. And then I also interviewed a final stakeholder group of individuals who are employees from a wide range of immigrant and health advocacy organizations in Greater Boston. And my goal was to really try to understand why

how various things happening in greater Boston, aside from health policy, might shape access to health care for immigrant populations. And so my interviews with those health advocacy organization employees was really valuable for better understanding the social context of Boston and some of the challenges that people might face. So

Briefly, those are the research methods for the study. I recruited participants for this study through basically starting to go around to a wide range of events in greater Boston, either that were around health care access or around immigration. And that way I was able to identify people to interview for the study from the three different groups.

And I also volunteered at a wide range of immigrant and health advocacy organizations. So when I started the project, DACA had just been implemented. And because I speak Spanish and Portuguese, I was able to use my skills at DACA clinics to sort of help people fill out their paperwork. Or if there was a citizenship clinic, I would help applicants that way. And so this was a way that I was able to better get to know some of these different communities, but also be able to recruit people for the study. Now,

After doing this research, what were some of the most surprising findings? Yes, I would say that the most surprising finding from the research was that

Over time, these policies that were theoretically supposed to extend access to health coverage, the Massachusetts Health Reform and the Affordable Care Act, also known as Obamacare, actually did the opposite for the Latino or the Latin American immigrant communities in the study. And so that was really surprising to me because both of these reforms, the purpose of them was to make sure that

that people had access to health coverage so that they could better get the health care that they needed. And for this particular segment of the population, that there were a lot of barriers that got in the way of shaping their ability to get access to coverage and to get access to care. One of those biggest barriers was documentation status, because under both reforms, documentation or legal status shapes your eligibility for the different coverage options that exist.

In Massachusetts, its reform allowed anyone in the state, regardless of documentation status, to be eligible to apply for coverage if you were at a certain income level. But once you reach that income level, your options were far more limited. And so documentation status played a role in that regard in the Massachusetts reform. And at the federal level, there are far higher level number of restrictions on documentation status.

under the ACA than there were under the Massachusetts reform. And so documentation status was the first barrier. Another barrier that came up a lot in the research was the issue of language and the fact that many of the enrollment materials that people had to use to sign up for health coverage under the Massachusetts reform or under Obamacare were often in English.

Many of the people that I interviewed, the immigrants particularly, had limited English proficiency. I ended up doing most of my interviews with those with the immigrant population and their primary languages in Spanish and Brazilian Portuguese.

And so if these people didn't have access to, you know, anyone in their social network that could say, hey, there's this organization that where you can actually call and get help in your primary language to apply for coverage, then you're not going to be able to apply for these coverage options, even if you're eligible to under law. And so that was a really big challenge that also sort of shaped the fact that

people, some of the immigrants I interviewed had difficulty accessing coverage. And for those that did access coverage, they had a difficult time using that coverage to find care because then they had to try to navigate the U.S. healthcare system with limited English proficiency. And it's very difficult to do that if you're trying to walk around the hospital and all of the signage is in English. If you need a medical interpreter and you're trying to convey that to, let's say, the receptionist at the front desk, who's

who might only speak English, and there aren't any resources available for you to say, hey, I need help in some other language, that becomes a barrier. And so documentation, status, language, and then the other issue that was really important that provided a barrier was the ways in which people were racialized.

um, and how that affected some of the ways in which they might've been targeted by law or immigration enforcement. And so for instance, I have stories that I write about in my book of people saying they got pulled over by the police on their way to a medical appointment. Um,

and they were afraid that being pulled over might lead to them being detained, or if there were immigration raids in their neighborhood the night before they had a medical appointment, they didn't go the next day. They would call and cancel. And so enforcement also played a really big role in also limiting this group's ability to access coverage and care, again, that they were supposed to be eligible for, theoretically, in the state of Massachusetts. So I would say that was probably the most surprising finding

that these people were not able to benefit from these extensive health reforms that were passed to, again, extend coverage to people by virtue of these other barriers getting in the way of that.

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Now, how does this book challenge the familiar narrative about race, immigration, and healthcare access in the U.S.?

So this book challenges those familiar narratives because I think one of the biggest ones, and I think we're seeing this now playing out in real time, but for much of the time over the course of my study, there was a lot of focus on the vulnerability of undocumented immigrants in the U.S. as being very much excluded, not having access to a wide range of resources by virtue of their documentation status. And so what I found, as I said, at the start of my work,

in a lot of the literature on immigration was that there was this perception or what I thought of as this binary between undocumented and documented immigrants with the presumption that documented immigrants were in a more protected position than undocumented immigrants. And it's very fair to say that undocumented immigrants are often and have often been very highly stigmatized in the U.S. And that vulnerability is very, very real.

But what I started finding in my research was that I would interview people who were green card holders, people who were naturalized citizens, who would also talk about their difficulties getting coverage, navigating the system, and then also being concerned about how the ways in which they were racialized in the U.S. also prevented them from getting access to the coverage and care that they needed.

And so what I tried to do in the book is really draw attention to how rather than there being an undocumented-documented binary, that there's really more of a citizen-noncitizen binary where there are a wide range of documentation status categories that exist between undocumented and citizen, but it's really anyone who's not a citizen in the United States is deportable under current immigration law.

Until you are a citizen, that does not provide, you don't really have full protection from deportation. And even in the last few months and under the first Trump administration, which I wrote about or I conducted data for this book or conducted research for this book about in 2019, that's the basis of Chapter 4,

You know, I've heard incidents of people who are U.S. citizens being pulled over, being detained by ICE, and if they didn't have any proof of citizenship, U.S. citizenship, that they could have been deported. And so what I write about in the book and what we're seeing happen now in U.S. society is that everyone's vulnerability has been enhanced, right?

Not only the undocumented, but we've been hearing about green card holders, people who were here on legal tourists and student visas, those visas being revoked.

We're seeing that all unfold right before our eyes. And I started noticing and recognizing this in my research on the ground way before this moment, sort of this vulnerability that people, regardless of what their documentation status are feeling, but in addition to that, people who are racialized as people of color, for

Particularly, even if they are U.S. citizens, I interviewed some naturalized U.S. citizens among my immigrant sample who shared that even though I am an American, I'm a naturalized citizen. They talked about how they felt like they would never be fully received and regarded and treated as such in the United States because of the history of racism.

racism in our society, and the connections between race and immigration policy that have been longstanding in the U.S. since the foundation of the country. So all of those things together basically collide with the healthcare system in this book. And I really write about how those challenges that documentation status pose, the racialization of immigrants as either Black or

or white or somewhere in the middle among these three different groups, Brazilians, Dominicans, and Salvadorans, how that also led to their differential experiences in the healthcare system in terms of how that created additional barriers to care. But in some cases, and I write about this in the book for Brazilians because they're racialized as white, um,

Dave made us say many, many times people talked about experiencing discrimination, but feeling that it happened because they were immigrants and not on the basis of race compared to Salvadorans and Dominicans who more often felt that any discrimination that they encountered in the health care system or in their everyday lives was both related to family.

the fact that they were racialized as people of color, but also they felt that they were very easily singled out as immigrant or different as well. And that was also related to language where people would say, you know, in it, I was interacting with someone and then they heard me speak Spanish or speak English with an accent. And then they targeted me and discriminated against me on the basis of that.

And so the other, I think, way that this book really challenges these familiar narratives about race, immigration, and healthcare access is really through putting a focus on language. The language that people speak, whether it's English or not. And then if they speak English with an accent. And again, I think in the present moment,

This is also something that's becoming increasingly important if we think about the fact that President Trump signed an executive order making English the official language of the United States. And again, trying to send this message that in this country, this is the language that we speak. And so for those who don't speak that language or maybe do not speak it with the proper accent, you could also be targeted on the basis of that, which is something that I also write about and found in my research for this book.

Now, what misconceptions do people have about the Affordable Care Act and its impact on immigration?

So I think one of the best misconceptions that people have about the Affordable Care Act is that it extends health coverage options to everyone. Undocumented immigrants, documented immigrants, everyone gets access. That's one of the biggest misconceptions that I often heard about Obamacare. And I'm even reminded of when President Obama addressed Congress yesterday.

And it's probably been over a decade ago, but or when much earlier in his presidency or shortly after the Affordable Care Act was either being legislated or signed into law, where Representative Joe Wilson from South Carolina basically stood up and shouted, you lie, when Obama said that undocumented immigrants would not get access to coverage under Obamacare.

And so actually what I found in my research, and I have a chart in the book that actually walks through the different documentation statuses that exist in the country or the most common ones that people are familiar with, and what your eligibility is under the Affordable Care Act.

And for most immigrants in the U.S., undocumented and documented, many of them are actually excluded from Obamacare provisions because of standing restrictions and federal law long term.

restrictions in federal law that actually limit who can have access not only to health coverage options under policies like the Affordable Care Act, but also SNAP or food assistance or Medicare or Medicaid and what have you. These federal restrictions exist across the board for across a wide range of public benefits that we have in our social safety net in the U.S.,

And the fact of the matter is many immigrants are excluded from most of these social provisions. And so in terms of thinking about the impact on immigration, another falsehood that I've heard over the course of doing this research in the media was that programs like the Affordable Care Act actually encourage immigration to the United States. And again, I think that is completely false.

Because, again, of these federal longstanding restrictions that we've seen that limit or bar people from the Affordable Care Act, from other types of policy provisions, because they are not green card holders who've been here for a long period of time, or U.S. citizens, or some other maybe protected immigrant group that's eligible for those benefits, like, let's say, people with refugee status or asylee status, for instance.

Now, in your book, you tell us a story about Victoria. Can you tell the audience about that story? Yes. So Victoria is a Dominican immigrant woman that I interviewed who had been in the U.S. for decades. She came to the U.S. from the Dominican Republic. And when I spoke with Victoria, she basically said,

talked about how over the course of her life, she's experienced a wide range of challenges in terms of, you know, integrating into U.S. society with regard to the fact that she's from the Dominican Republic. Her primary language is Spanish. So, you know, she struggled to learn English. We did our interview in Spanish.

She also talked about the fact that she's experienced discrimination throughout her life because she is thought of and seen by others as an immigrant and particularly as a Latina immigrant because of how she looks, but also because of the fact that she speaks Spanish and how that shaped her experiences. And then she also told me about a wide range of health issues that she's had or that at the time that I interviewed her back in

When I started this project, a wide range of health challenges that she had, vision problems, problems with high blood pressure, a number of other challenges that she talked about. And these health challenges were so great and so severe that she had to basically walk away from the job that she had and go on disability because she was no longer able to effectively work.

And at the same time that Victoria talked about some of these health care challenges that she experienced, she mentioned that she felt really fortunate to live in a place like Massachusetts and particularly greater Boston because of the world class health care facilities that are here that have been touted as some of the best in the country, some of the best in the world.

They're affiliated with some of the best medical schools in the country and in the world as well. And so how this has really led her to feel like, and I opened the book with a quote from her basically saying that Massachusetts is a great place that's known for its health care.

And even though Victoria acknowledged that she felt really fortunate to live in Massachusetts and particularly greater Boston because she feels that she's able to get the care that she needs, she also explained that she's experienced discrimination in this healthcare system. Some of it related to providers maybe not having a medical interpreter available. So there being challenges with regard to them understanding her, her understanding them.

her also feeling like sometimes providers just did not listen to her. And so there were points in the book or also earlier in the book when I talk about Victoria, she talked about how she also had had some mental health issues and that when she was trying to get help from a provider that the provider did not believe her, took her off of her medication, and then Victoria just kind of spiraled.

And so in this particular case of Victoria, I thought it was so interesting that on the one hand, in our interview, she basically praised the Massachusetts health care system. And in that same interview, she also talked about blatantly not being able to receive adequate care.

because of discrimination that she experienced in that same healthcare system. And so I think that Victoria's experience is really indicative of a lot of people's experiences with the U.S. healthcare system in terms of thinking about the challenges to understanding how it works, finding providers that people feel like will listen to them and be compassionate in terms of trying to figure out what is going on in terms of whatever health issues might be emerging.

But also just in terms of having Victoria being, having to feel like she needed to be very proactive about trying to also seek out providers that would provide support

that she thought would be mindful of the fact that, you know, she has this immigrant background. She's been in the U.S. for a long time. English isn't her first language. And so also having to be proactive about trying to seek that out and sometimes experiencing difficulty doing that.

And so, as I mentioned, I think Victoria's experience really epitomizes and shows how so many people encounter a wide range of challenges in our healthcare system. Again, a healthcare system that's acknowledged globally as having some of the best in the world, but at the same time is not the most accessible by many of us in our everyday lives whenever we get sick trying to figure out what can we do and where can we go to get the care that we need.

Now, what ways does the ACA help undocumented or recently arrived immigrants and where does it really fall short?

So to go back to, I think, something I said a little bit before about longstanding restrictions and documentation status and federal policy across the board, whether that be health policy, welfare policy, immigration policy, or what have you, the ACA really does not provide much help, certainly for undocumented immigrants in terms of the coverage options that are available.

And so if we think about the ACA provisions are some of the most common ones. There was the Medicaid expansion, which was used to be able to expand access to coverage for people who were lower income. And it raised the original threshold for Medicaid eligibility. It made it a little bit higher so that more people would be eligible, more lower income people would be eligible for the Medicaid expansion.

And then for people who are middle income, another provision of the ACA provided subsidies for people to be able to buy coverage in the health exchange. So the health exchange was basically a website that was set up where people could go, put in some information about themselves, and then they would be presented with some different health plans that they might be able to apply for coverage for using those subsidies. And so again, again,

Access to Medicaid, but also to the exchange was limited for undocumented immigrants. In terms of recently arrived immigrants, again, it goes back to whatever particular documentation status that you have. If you are arriving as a refugee or with asylee status, you have access to far more options under the ACA provisions than certainly an undocumented immigrant.

If you're a green card holder who's had that status for five years or more, or you're a U.S. citizen, you're also eligible for most of the Affordable Care Act provisions. But in terms of green card holders who've had that status for less than five years, there's also a five-year bar in U.S. welfare policy that limits green

green card holders with that status for less than five years from being eligible for a number of public benefits or provisions in our social safety net. And so in terms of thinking about the ACA and where it falls short, it really depends on one, your documentation status and how that shapes your eligibility for those different coverage options.

But it also depends on what state you live in. So here we are in 2025, the Affordable Care Act was signed into law.

15 years ago on March 23rd. And there are still some states in the United States or in this country that have not expanded Medicaid for their populations. And so what that means is that you have a number of lower income citizens in our country that still have not been able to benefit from the ACA because they happen to live in a state that did not expand Medicaid. And

And so this is, I think, one of the or another way that the ACA falls short, that everyone has not been able to benefit from the ACA either through exclusion and policy for certain immigrant populations, for instance, or

or if your income level doesn't meet the eligibility or is, I should say, is above the eligibility criteria for the different coverage options. And then if you're a citizen that lives in a state that didn't expand it, you also have not been able to benefit. And so the ACA, though it was not a perfect reform and though it's had some challenges,

It still has done an important job of increasing access to coverage for people who were eligible for it and who lived in states that expanded Medicaid as well. So in terms of where it falls short, unfortunately, it didn't provide universal coverage. Now, do you think we're moving towards a more inclusive health care system or are we seeing increased restrictions?

I would definitely say that we are seeing increased restrictions or a health care system that's becoming more exclusive. And just in terms of thinking about some of the policy debates that are happening coming out of the federal government right now or what we see unfolding in D.C.,

is that we're starting to see more increased restrictions in terms of programs that have been longstanding programs that many Americans have either thought they would have access to and they don't. So in terms of thinking about these proposed Medicaid cuts that have been floated by Americans,

by the House or by Congress. If that goes away, a significant number of people will lose their access to coverage across the country in blue states and red states alike. And it's interesting because many of the people who benefit or who have Medicaid coverage live in states and are people that have voted for this administration. And at the same time, later this year,

This year, the subsidies that I mentioned under the ACA that allow people who are middle income to buy coverage in the health exchanges, those subsidies are due to expire. And based on what I'm seeing in this current policy context, it doesn't seem like there's going to be much political motivation, at least by the party in power, to extend those subsidies. And so that means that a number of middle income people have the potential to lose their coverage.

There's also been discussions around whether or not Medicare might also or parts of it might change or also be on the chopping block. And Medicare is a longstanding program that's been in place for our community.

Older citizens, people who reach retirement age, who've basically paid into this system when they were working because it comes out of our taxes or our paychecks, who might also see some restrictions or some changes that might also have some negative impacts on their health care access.

And so with all of these discussions happening, I'm not hearing anything about how are we going to replace this system. I write about in Chapter 4, which focuses on the year 2019 under the first Trump administration, when there were efforts to repeal and replace Obamacare. So at that time, there was discussion of we're going to get rid of Obamacare and replace it with something else.

I haven't heard any of that discussion this time around as I've been hearing about these proposed policy cuts to programs like Medicaid, to these tax subsidies, to what could happen to Medicare. And my concern is that

If you're going to get rid of these programs without any sort of replacement, what are people supposed to do when they get sick and they need coverage and they need care? And that's a really big question that I would like to see these legislators answer since they seem so enthusiastic about this.

Basically, increasing restrictions on health care access. And this is not only a lot of my focus and not all in was about immigrant populations, but what we're seeing is that a lot of the restrictions that immigrants have been facing in access to health coverage.

and other aspects of the social safety net for the last few decades, now that's shifting to citizens where citizens who are supposed to be legally entitled to these benefits are being cut out from these programs that have been so beneficial. And so it's really troubling to see these developments and these increased restrictions at a time when people are

when we have a measles outbreak that's happening, when we have other health issues that continue to be, that people continue to have to deal with and navigate. And also too, we're not that far removed from the COVID pandemic. And so it's really troubling to sort of see these developments when we have a wide range of health, general health issues, but also public health crises emerging in our country.

Now, what policy changes would you want the men to ensure better health care access for all immigrants? Well, I write about some of these things in the book, and I recognize that in this current policy context that many of these recommendations that I have will likely not come to pass.

First and foremost, one of the things that I advocate for in the book is comprehensive immigration reform that provides a path to citizenship for people who have been in this country for a very long time, who are contributing to our society, who are working, who have businesses, who are taking care of our children, who are taking care of our older Americans in nursing homes, who are

who are doing the work that keeps America running. I think that immigration reform is really, really important because it will reduce some of these restrictions in documentation status that currently exist that limit people's ability to benefit from reforms like the Affordable Care Act. So that's one policy change that I would recommend.

In terms of the Affordable Care Act, if there were ways to remove those restrictions based on documentation status that people face who are not citizens or who are

not eligible, currently eligible for coverage options under the ACA, if you remove those restrictions, then that allows more people to access the system. It also allows more people to buy into the system and to be able to buy coverage. So another thing that is really interesting about the ACA that I forgot to mention earlier

earlier, is that in the health exchanges, if you're an undocumented immigrant, you can't even use your own money to buy coverage in the health exchange. And so if that was another restriction that were removed, then again, you would have more people contributing to the overall health insurance pool that would make the system more stable in terms of people being able to

or the system being able to absorb the healthcare system and the health insurance system, being able to receive more revenue, but also being able to distribute that more among a population or the broader population. The other thing that's really important to mention in this discussion is that a lot of research is basically

demonstrated and documented that immigrants that come to the U.S. are typically healthier than U.S. born individuals or people who've been here all their lives. And they tend to be younger when they arrive. And so usually people have better health when they're younger. And as they get older, we have more health issues. And so if immigrants who have

who are coming to the U.S. when they're younger and who also have better health are able to, again, participate in the system by being able to purchase coverage, then this also increases the pool of healthier people so that

It affects the, in terms of thinking about the ways in which health insurance works, sort of the pool and the costs associated with it as well in terms of how that money gets redistributed among people who have health coverage. And so that's really important to think about as well. So I would say those are probably two of the policy changes, at least at the federal level around healthcare access that I write about in the book.

Well, tell us some of the personal studies or case studies from your research that stood out the most. Yes. So one of the studies that stood out the most to me, I should say one of the personal stories rather, that stood out to me from my research was an interview that I did with an immigrant advocate.

And she did this or I did this interview with her in 2019. So I write about this in chapter four of the book. But basically, she was talking about the amount of fear that immigrant communities were facing under the Trump administration.

under the first Trump administration. And she told me the story about this immigrant family, mother, father, and a young child, young child that had health issues, and that they wanted to take their child to the hospital, but they were too afraid to call the ambulance. And so they decided that they would try to drive the car, the child in their car to the hospital. And

And basically the child died on the way to the hospital because they couldn't get there quickly enough because in their car, they didn't have sirens that would be able to sort of have people to get out of the way on the way to the hospital. And so that story really stayed with me because I really thought about the fact that these parents who wanted to do the best for their child, but who also felt constrained about around the fear of

of trying to call an ambulance for help because they thought that they could lead to them having to give information about themselves and that that could eventually lead to their detention.

And that was the risk that they had to weigh as parents. And I have to say when I was doing the research for this book at that particular time, I wasn't a parent and I am now. And that story is just so chilling to me because I think about, again, as parents, we want to do whatever we can for our kids.

And having to think about, I'm too afraid to call an ambulance to get my child where they need to be, is something that just really was heartbreaking to read about. Another, I would say, part of the book or another story that stood out to me as well that I also sort of, that I think speaks to this moment is,

of really heightened sociopolitical tensions, heightened discrimination and sort of hatred towards other people was from a provider that I interviewed who identified as being of Central American background and who basically told me that one day she was on her way to work

And basically a white woman threw hot coffee at her when she was walking down the street and that this person then said to her,

You should be out of here. Go back to your country. And this person that I interviewed, this provider was a naturalized U.S. citizen. And she was just stunned that that happened. And when she told me that during the interview, I was stunned myself. I think it was hard for me to find my words probably for a few seconds after that because I was just shocked that anyone could do something so explicitly hateful.

and mean-spirited, but also dangerous to throw hot coffee on someone and to just keep walking like it was no big deal. And so I think it really speaks to this moment that we're in in terms of just the level of lack of humanity and care that many of us, or that some of us, I should say, demonstrate for one another just as human beings and really how troubling that is. And then I guess I'll just say one other story

story from the book that stands out to me was also another interview that I did with a healthcare provider, another healthcare provider that talked about how when he started his career practicing medicine, it was right before the 2006 Massachusetts health reform got implemented. And

And he shared with me that he felt like as a provider who sees immigrant patients and some of them are undocumented, that he felt like he had an easier time or his patients had an easier time getting access to coverage and care when he started his career before the Massachusetts health reform was implemented.

And then he also talked about specifically that even after the ACA got implemented, that it just became more and more difficult. And by the time that I had re-interviewed this provider in 2019, he just basically said, I have a really hard time with a number of my patients just not being able to get coverage anymore.

And again, I think this goes back to one of the surprising findings that I shared and I write about in the book, that these reforms are supposed to extend access to coverage. And here I have this quote.

on this healthcare provider and some other healthcare providers also mentioned similar sentiments that many of their immigrant patients are having a much more difficult time getting access to coverage. Now, you know, 15 years after the signing of the ACA, you know, in terms of this comprehensive health reform compared to almost 20 years ago when the original Massachusetts health reform came into place. And again, a lot of that,

the access challenges are around some of the barriers that I mentioned and already talked about a little bit earlier. Now, what were some of the challenges you faced in writing and researching this book? Yes. So challenges doing the research for this book. Oh my goodness. So first of all, I'll just say that I did all of the interviews for this project and

I interviewed over 200 people over the course of nearly a decade, and those interviews were in multiple languages. So I did interviews in English, Brazilian, Portuguese, and Spanish, depending on the preference of the person that I was interviewing. And so even just thinking about conceptualizing this project in the different interview protocols or questionnaires, it

that I used, each one had to be different for the different stakeholder groups. So the immigrants, their interviews were a lot longer because I wanted to find out more about their background before they came to the U.S., what led them to come to the U.S., you know, what their experiences have been in greater Boston since they arrived, experiences of discrimination, access to coverage, challenges with the health care system.

And many of those interviews I had to, as I said, do in different languages. So the interviews I did with Brazilians had to be in Portuguese, were typically in Portuguese. Those with Dominicans and Salvadorans tended to be in Spanish. So just in terms of that group having to do different interviews in different languages for the immigrants and for the providers and the advocates.

definitely was a challenge in terms of basically having to change between languages. Sometimes I do multiple interviews in one day and having to go from English to Brazilian Portuguese to Spanish or from interviewing an immigrant to a healthcare provider to an advocate certainly was just sort of like just physically and mentally draining at times.

So the process of actually doing the research and driving all around and also taking the T of public transportation, you know, all of that really, really was very difficult at times and a really big challenge of the work.

Another big challenge was just some of the stories that I heard, some of the ones that I shared earlier and that I write about in the book in terms of just the level of fear that people were feeling, particularly as the sociopolitical climate became increasingly hostile towards immigrants and to people of color.

And, you know, in our country and also in greater Boston, I write about some incidents in the book as well that either people that I interviewed personally experienced or either things that happened that were written about in local or written about or covered in local media around some of these experiences of people being targeted and singled out and discriminated against on the basis of their perceived group membership. So that was really hard hearing some of those stories.

And a really big challenge too was keeping up with the policy changes over time.

In terms of what was happening at the federal level with regard to, you know, understanding eligibility criteria with the ACA when they're in the Supreme Court, the Supreme Court cases that, you know, challenge the constitutionality of some aspects of the ACA, you know, wondering, OK, does that mean what are going to be implications for the research that I'm doing if this policy goes away?

The Massachusetts health reform as well. When I started the project, that was the reform that was in place in Boston in 2012 to 2013 for the first year that I did interviews for the book. By the time I came back in 2015, 2016, that policy context was gone. And it was the ACA that was sort of

That was in place in Massachusetts at that point. And so it's really trying to understand the differences between the two policies, especially eligibility criteria based on documentation status was very, very confusing. And so if that was confusing for me as a researcher, you know, who's been looking at these issues for a decade now,

And even some of the health advocates that I interviewed, I would have to be like, wait, can you explain this to me? Like people who are like health attorneys and whatnot, because I'm not fully following it. And they would say it is very complex and hard to understand. So that was another challenge.

And I think also, too, thinking about other policy areas that intersect with health policy. So, again, most explicitly immigration policy in terms of the documentation status restrictions, but also thinking about how sometimes state level or subnational policies intersect.

contradict policies happening at the federal level. And then the impact on the ground is just a lot of confusion for people who are trying to connect people with access to care and to coverage. And so I mentioned earlier that the Massachusetts reform, there was eligibility for everyone, every resident, regardless of access, sorry, regardless of documentation status, if their income level was low enough.

But at the federal level under the ACA, once it fully was implemented,

there were more restrictions based on documentation status. And so what that meant was that on the ground in greater Boston, if you had healthcare navigators or people trying to connect people with coverage, sometimes immigrants would be told they were not eligible for any coverage options under the ACA, even though they might've been eligible for something under the Massachusetts in terms of state level reforms that were still kept in place

and had been reconfigured to be able to link up appropriately with the ACA. So the policy piece, just really trying to understand that, navigate that, and be able to write about it in a way that other people can understand was also really challenging as well.

And I think the other piece is just really trying to think about how I wanted to conceptualize the racialized legal status framework that I write about in the book in terms of thinking about the important intersection between race, ethnicity, and documentation status, and how it plays out at different levels in our society. So I feel like

It took me doing the research for years and the process of analyzing the data to really be able to understand that.

why it's important to look at the intersection of race, ethnicity, and legal status or racialized legal status and what it can tell us about people's experiences with the healthcare system, but also their larger society, the larger society. That also was a really big challenge for me trying to basically put all of this together in the writing of the book.

Now, what do you hope the readers take away from your book and what action should they consider taking? In terms of what I hope readers take away from the book, I hope that readers are able to get a better glimpse of how our health care system works and

Through me walking through that experience or sharing about or writing about that experience from the perspective of people on the ground who are trying to navigate that system in their individual lives. Either as people who were trying to get care, which were the immigrant populations that I interviewed for the book, The Immigrant Sample.

the people who are trying to provide that care from the lens of the healthcare providers, healthcare professionals, and then also from the individuals who try to connect people with the healthcare system and other types of social services. So the immigrant and health advocates, right?

I really want people to understand that even though our healthcare system is very, very complicated, that it is something that all of us have to navigate and that we shouldn't be the ones responsible for that burden of navigating this complicated system that we didn't create that has resulted in some of the highest healthcare costs globally and

And at the same time, for us in the U.S., we often or we still have worse health outcomes compared to people in peer countries. And so what I want people to understand is that these health care reforms have been really, really important for extending access to coverage and to care. But

that it is still very complicated. It's still very hard to navigate and more needs to be done to make that process easier to navigate, to make the system easier to navigate. And also that it's

in terms of writing about the immigrant experience or primarily from that perspective, I really want people to understand that even though immigrants are very highly stigmatized in our country, that these are people just like us, or they're just like everyone else. I should say, um, that they are working China to make a living, to support their families, to take care of themselves, to contribute to our society. Um,

And that, you know, they should be able to benefit from this society in terms of what they're contributing to it. And one of the ways that we can think about doing better is making sure that everyone can benefit from our health care system, that it shouldn't matter where you were born or what your income level is or what your state, the state you happen to live in, that when people get sick, everyone should be able to get the care that they need.

And I think that's really, really important that we really need to do a better job of taking care of each other in this country rather than,

stigmatizing or blaming or trying to use divisive rhetoric to basically dehumanize each other and tear each other down in a time when we really should be thinking about how we can collectively improve our country by making sure that everyone has what they need to take care of themselves, to have appropriate housing, healthcare access, and what have you.

And in terms of action, people should consider taking, um, writing to your lawmakers. Um, I know it seems probably in this moment to, you know, feel very, to feel very concerned, um, and probably even a little dismayed about what can be done in this moment. But people, we definitely need to still take concerted political action, um,

and to do what we can to try to move the needle, even when it seems like the situation is very difficult, which it is in this current moment. Well, I've taken up enough of your time. Can you tell us the next project you'll be working on? Yes. So in terms of the next project, one of the things that I am thinking about as an extension from this particular project is

is, I guess, maybe a couple of things. One thing that I've been thinking about and that came up over the course of this study was some of the older immigrants that I interviewed and wondering, you know, when these people reach retirement age and won't be eligible for Medicare, assuming it still exists,

what are these people going to be able to, what are they going to be able to do to get access to coverage and care? Because there won't really be any options for them. Those options don't currently exist. And so just wondering, as people get older, particularly as immigrant populations get

get older and they're not eligible for some of these long established social safety nets for older Americans or eligible, I should say,

for older people living in the country who have the, who are eligible, you know, for things like Medicare and social security and older age, you know, what is going to happen to these older populations of immigrants who don't have access to that? Especially since we're already starting to, you know, sort of see this demographic shift to, you know, with people living longer, the challenges, health challenges that people have as they get older in life and,

get people experience later in life with often needing assistance at home. So home healthcare aides and a lot of that work, by the way, is being done by immigrants in the present right now as we speak. So that's one project that I'm thinking about sort of what happens to people, immigrants as they get older and can't access, formally access the system. And then another project that I've also been thinking about

is really wanting to understand more around the role of language and how it is the basis for people experiencing discrimination in terms of, again, if they don't speak English or if they speak English with an accent and how language is something or a factor that can also racialize people or others them.

and really trying to understand more about that particular relationship, which I think, again, was a really pivotal theme that I think came through quite strongly in this book project.

Well, we'll be looking forward to all of those projects. And again, we have been talking with Dr. Tiffany D. Joseph, the author of Not All In, Race, Immigration, and Healthcare Exclusion in the Age of Obamacare. Thank you so much for being on the COMP Podcast. All right. Thank you so much for having me. It was a pleasure.