(Image by Gerd Altmann via Pixabay)

IN 2006, Massachusetts made history as the first state to pass comprehensive health reform, creating a national model for near-universal health coverage. Even more remarkable, the Commonwealth extended that coverage to noncitizen residents at a time when many states were moving in the opposite direction, tightening immigration restrictions that cut immigrants out of health care.

Twenty years later, income-eligible immigrants of any status in Massachusetts can still apply for coverage. Yet immigrants remain far more likely than citizens to be uninsured, even in a state where less than 3 percent of residents lack coverage. Why?

The answer lies at the intersection of race, ethnicity, and legal status – what scholars call “racialized legal status.” Despite Massachusetts’s inclusive policies, structural racism and legal status discrimination have consistently undermined immigrants’ access to care, creating barriers that persist even for those who have coverage.

From 2012 to 2013, I explored how Brazilian and Dominican immigrants navigated the health care system under the Massachusetts reform. Through more than 70 interviews with immigrants, health care providers, and advocates, I identified four ways racialized legal status blocked access to care: coverage enrollment, language barriers, discrimination in the health care system, and fear of immigration enforcement.

Coverage gaps were built into the system. Legal status determined which coverage immigrants could access – and where they could use it. Citizens and certain green card holders could choose from more robust coverage options accepted at a wide range of facilities. Conversely, undocumented immigrants were largely limited to the Health Safety Net program, usable only at designated facilities. Even immigrants eligible for MassHealth, the state Medicaid program, sometimes struggled to find providers willing to accept their coverage, given Medicaid’s low reimbursement rates.

As Dominican advocate Miranda put it: “In the health centers, the person who has private insurance gets taken care of more seriously. The clinics get those with public insurance. In hospitals, the people with private insurance, they get a better experience.”

Language barriers shut people out. Many immigrants with limited English proficiency struggled to complete enrollment paperwork without assistance in their primary language. Under Title VI of the 1964 Civil Rights Act, language is a recognized marker of race, making this a form of racial discrimination.

Language barriers didn’t stop at enrollment. Immigrants who needed medical interpreters reported delayed wait times. Francisca, a Brazilian immigrant, described her husband’s situation. When neither she nor her son could accompany him, she said, “it takes him longer to be seen. If you need an interpreter, you could wait two or three months to get appointments.” Some gave up on care entirely.

Discrimination followed immigrants into health care facilities. A Dominican immigrant named Dania bluntly described her experience: “I have definitely experienced discrimination, of us being abused and mistreated in hospitals for being Latino or an immigrant. They leave you waiting for hours until you’re almost dead to treat you.…Discrimination has always existed and not only because of our skin color, from the moment we open our mouths.”

Because Americans so often conflate immigration with Latinos, even naturalized citizens I interviewed reported being treated as undocumented. Speaking another language – or English with an accent – was enough to trigger mistreatment.

Fear kept immigrants from seeking care at all. For immigrants of various legal statuses, the risk of encountering law and immigration enforcement made basic activities feel dangerous. Rosalicia, a Brazilian immigrant, explained: “You think twice before you go anywhere, driving, you live on the margins of society, you’re not included. You can’t go to school because you’re afraid, or the hospital either.”

Health care providers felt the impact too. After ICE raids near T stations in East Boston, a provider named Gloria recalled: “That day we missed a lot of patients, and we did not know what was happening.”

Though Massachusetts health care reform successfully included immigrants in its coverage provisions, racialized legal status barriers worsened access to care. When I returned to this research, conditions had deteriorated in 2015 and 2016 and again in 2019 – first under Affordable Care Act implementation, then amid ACA repeal and replace efforts during Trump’s first term.

Now, under the second Trump administration, the stakes are higher for everyone. Aggressive immigration enforcement, systematic dismantling of ACA provisions, and the 2025 One Big Beautiful Bill Act are extending to citizens the same exclusions immigrants have faced for decades. The future of Massachusetts’s landmark health reform is now in jeopardy, and the state faces difficult fiscal choices.

But Massachusetts is rising to the challenge. Pending legislation – including the Language Access and Inclusion Act and Act to Advance Health Equity – aims to allow patients to receive quality care regardless of documentation status and language ability.

State representatives also recently passed the PROTECT Act, which prohibits law enforcement from inquiring about individuals’ immigration status and bans the use of state and local resources for federal immigration enforcement. While the PROTECT Act requires the governor and attorney general to provide multilingual guidelines for handling ICE interactions in health care facilities, it stops short of banning ICE from those settings.

The state is also redirecting state funds to shore up coverage programs and reduce dependence on federal dollars while local advocates push to protect coverage for noncitizen residents.

Twenty years ago, Massachusetts led the nation in health reform. It can lead again – not by protecting coverage only for some, but by defending and improving care for everyone, including the most vulnerable.

Tiffany Joseph is an associate professor of sociology and international affairs at Northeastern University. She is the author of Not All In: Race, Immigration, and Healthcare Exclusion in the Age of Obamacare.