Professor’s new book explores health care barriers for immigrants in Boston area
“Access to health coverage does not guarantee access to health care,” says Northeastern professor Tiffany Joseph, who spent eight years researching health care access in Boston’s immigrant communities.
In 2011, Tiffany Joseph was in Governor Valadares, Brazil, working on her dissertation on return migrants, people who moved to the United States and back again.
When talking with her subjects about their time in the United States, Joseph found a portion of these interviewees said they struggled to access medical care when they lived in the Greater Boston area, despite Massachusetts’ renowned health care system and affordable insurance plans offered by the state.
Joseph wanted to look into this further. What started as a one-year project turned into years of research that became Joseph’s latest book.
“Not All In: Race, Immigration, and Healthcare Exclusion in the Age of Obamacare” looks at the shortcomings of Massachusetts’ health care system when it comes to immigrants, despite all the policies the state has implemented to try to reform this system.
“I really wanted to find out if you’re living here, can you benefit from these reforms?” says Joseph, an associate professor of sociology and international affairs at Northeastern University.
Her biggest takeaway in the book is that access to health coverage does not guarantee access to health care.
“Policies like the [Affordable Care Act] were theoretically designed to extend access to health coverage, but that is the first step,” Joseph says. “It doesn’t guarantee access to care because of all these barriers that people might face on their way trying to get care.”
From 2011 to 2019, Joseph interviewed immigrants from Brazil, El Salvador and the Dominican Republic, as well as health care providers and employees from immigrant and health advocacy groups. She spoke with over 200 people in addition to attending community meetings and statehouse hearings, and volunteering with organizations that dealt with immigration in health care.
“At that time, Massachusetts, because of its reform in 2006, was getting all this national attention because that reform became the model for the Affordable Care Act,” Joseph says. “There was all of this national praise about Massachusetts health care, and for me, I was thinking about those returning migrants from Brazil that I interviewed who talked about having difficulty getting access to health care when they lived in Greater Boston.”
Joseph decided to focus on Brazilian, Dominican and Salvadoran immigrants not only due to the large population of people from these countries living in Massachusetts, but because of the diversity of experiences among these groups.
“When people think about the Latino label in the U.S., this group is thought of as a homogeneous monolithic group,” she says. “What I wanted to do was try to look at health care experiences among groups under this Latino label, but from different countries and [with] different documentation status. These groups are also racialized differently.”
Joseph says the people she spoke with ranged in immigration status; some were undocumented while others were naturalized citizens or had temporary protected status. Their English proficiency and perceived race also varied. Joseph says Salvadoran immigrants were more likely to be viewed as Latino as opposed to Brazilians or Dominicans.
Over the course of her research, Joseph found that while Massachusetts offers insurance plans for many residents, including people who are undocumented, there are other obstacles that make it difficult for immigrants to then access health care.
For example, at the time of her research, Massachusetts did not issue driver’s licenses to undocumented immigrants. Joseph found this means some immigrants had insurance but no way to get themselves to doctor’s appointments unless they lived near public transit. She also found many undocumented immigrants struggled to get proof of residence (like a bill in their name or a lease) to even apply for coverage.
Language barriers also led to further obstacles to accessing care. At the start of the study, Joseph says most of the enrollment materials for affordable insurance plans were in English, which posed a challenge for people for whom English was not their first language. Language barriers also posed issues when it came to making appointments.
While assistance or medical translators are available, Joseph says some people weren’t aware of these resources. She also found that there were often delays in using translators. Some of the health care providers she spoke to said they had patients show up in their office to get a translator to make an appointment because they couldn’t speak English with the receptionist over the phone.
The political climate also played a role, Joseph says. Some of the immigrants she spoke to faced discrimination at times because they “looked” Latino, leading people to target them because they assumed they were undocumented. This prompted some to skip appointments, even if they were documented, out of fear of being targeted.
“As our socio-political climate became more explicitly racist and anti-immigrant and particularly targeted people who looked Latino or who were presumed to be undocumented … people like the ones that I interviewed in my study, oftentimes felt like they were targeted by law enforcement, immigration enforcement, or in their everyday lives,” Joseph says. “This also had an impact on the health care decisions that they made. For instance, if there were immigration raids in their neighborhood the night before they had a medical appointment, they weren’t going the next day.”
The United States health care system as a whole also posed significant barriers, Joseph says. For example, some of the people she interviewed came from countries where they could see a specialist without seeing a referral, but here, they had plans that required them to see a primary care physician before seeing specialists. Even those who are fluent in English struggled with some of the language used around health care like understanding deductibles and PPOs.
“These sorts of things I still struggle to navigate and I’ve been doing research on this for over a decade,” Joseph says. “For some of the immigrants that I interviewed, the health care system is completely different in their country of origin. … Even when you have coverage, [understanding the U.S. health care system] is a big challenge.”