Red tape and racialized legal status: how Boston’s migrant health safety net unraveled

Tiffany Joseph's 2025 book Not All In explains how Dominican, Salvadoran, and Brazilian immigrants in Boston, Massachusetts, navigate a healthcare system horribly transformed by the collision of new federal health care programming with formerly successful state-level care. New state reforms followed the Affordable Care Act, and the new offerings, ironically, blocked immigrants' access to care. Inconsistent information, restrictive eligibility rules, increasingly violent federal anti-immigration captures, and barely existent federally mandated language translation services, made it nearly impossible to get care. As a result, many wait ill or injured to fly home to readily available full-coverage care rather than risk navigating the world's most expensive and inaccessible health care system. In the end, I interrogate the phrase “not all in” to explore the implications of Joseph's rendering of this health care labyrinth.