Tiffany D. Joseph's "Not All In"

Tiffany D. Joseph is Associate Professor and Graduate Program Director of Sociology and International Affairs Program at Northeastern University. She is the author of Race on the Move: Brazilian Migrants and the Global Reconstruction of Race.

Joseph applied the "Page 99 Test" to her new book, Not All In: Race, Immigration, and Health Care Exclusion in the Age of Obamacare, with the following results:

From page 99:

[The explicitly racist and anti-immigrant rhetoric of the] …past decade has generated a climate of fear that has diminished Latinx and other immigrants’ willingness to seek health care around the country and even in Boston. These themes surfaced among the individuals I interviewed in 2012–2013. They encountered language-based difficulties in making and scheduling appointments and obtaining transportation, suffered from providers’ implicit and explicit discriminatory treatment, and feared being profiled and detained on the way to appointments, which could lead to their arrest and deportation. Thus, racialized legal status discrimination was pervasive in Latinx immigrants’ experiences with the Boston healthcare system.

How Language Hinders the Medical Encounter

Limited English proficiency (LEP) hindered immigrants’ communication with healthcare providers, which intensified all the other forms of discrimination they might encounter. For the estimated 25 million individuals in the United States with LEP, language presents a huge structural barrier to obtaining health care, from scheduling appointments and seeing providers to filling and accurately taking prescriptions. While the inability to obtain necessary information in one’s primary language may seem an inadvertent consequence of migration, it represents a violation of anti-discrimination law. As I discussed in Chapter 1, Title VI of the 1964 Civil Rights Act protects the right of individuals to receive language-appropriate information and assistance in federally funded institutions. Consequently, the inability to receive such assistance is a form of racial discrimination, which compromises LEP individuals’ engagement with meso-level institutions. Like many primary English speakers, I previously took for granted the privilege of making appointments and communicating with healthcare professionals in my primary language. As I interviewed stakeholders, I realized how many patients ran into these racialized legal status barriers when attempting to obtain health services.

I asked Brazilian and Dominican respondents about the quality of their interactions with medical providers. Francisca, the Brazilian who complained that the government made it difficult to apply for coverage,…[described the problem her family faced when getting care].

The Page 99 Test definitely applies to my book and gives a reader a good idea about the central themes of Not All In with regard to how racial and anti-immigrant discrimination negatively shape immigrants’ healthcare access. This page references how language, specifically having Limited English Proficiency (LEP), is a tremendous barrier to all aspects of navigating the healthcare system. First, having limited English proficiency (LEP) makes it difficult to schedule appointments. Second, language differences limit effective patient-provider communication and may result in longer waiting times if medical interpreters are unavailable. In both cases, immigrants reported feeling that providers mistreated them or were inpatient when additional language resources were needed. Thus, language – either not speaking English or speaking with an accent – was a crucial factor that sometimes contributed to immigrants’ experiences of discrimination in the healthcare system and their broader lives.

Not All In confirms a stark truth about our healthcare system: health coverage does not guarantee access to health care. Obamacare was a historic reform, but everyone has not benefited from it due to policy design (for immigrants) or lack of policy implementation (for Americans in states that did not expand Medicaid). But, even when people have coverage, like most immigrants I interviewed in the book, they experienced significant barriers to enrolling in coverage and then getting care with that coverage. Their limited English proficiency made it difficult to schedule appointments and effectively communicate with providers, particularly if medical interpreters were not available. Beyond that, long-standing documentation status restrictions in health policy alongside structural racism in the healthcare system meant immigrants experienced discrimination based on their racialized legal status – the intersection of race, ethnicity, and documentation status. Fears of being pulled over by police or immigration enforcement in route to obtaining care also made immigrants afraid to see their providers. Though the book focuses on immigrants, most of us can relate to not understanding complicated insurance lingo, finding a primary care provider taking new patients or with certain insurance, or effectively communicating with our doctors. But the most marginalized among us must contend with explicit and implicit discrimination that make it more difficult to obtain the best quality health care we can get.

Visit Tiffany D. Joseph's website.

The Page 99 Test: Race on the Move.

--Marshal Zeringue