WHEN TIFFANY JOSEPH began writing about the experience of Brazilian migrants who traveled to the United States, a specific set of anecdotes burrowed into her mind for more than a decade: Immigrants, some undocumented, were returning to Brazil earlier than expected because they were more confident about the health care system in the country they left.

Flash forward to her 2011-2013 post-doc research with the Robert Wood Johnson Foundation at Harvard: Health reform in Massachusetts was drawing national attention, and the state touted its high rates of health care coverage. Joseph started probing how immigration status could limit access to federal aid programs.

“I wondered,” she said on The Codcast, “if you’re an immigrant living in the state of Massachusetts, can you benefit from this health reform that’s getting all this national attention and became the model for the Affordable Care Act?”

This week on the monthly Health or Consequences episode of The Codcast, John McDonough of the Harvard TH Chan School of Public Health and Paul Hattis of the Lown Institute talk with Joseph, assistant professor of sociology and international affairs at Northeastern University, about her new book, ‘Not All In: Race, Immigration, and Healthcare Exclusion in the Age of Obamacare.’

Discussion about immigration and system strain, Joesph said, can be driven by “misconceptions” about what immigrants can access in the United States. Documented and undocumented immigrants are restricted by federal law from programs like Medicaid, social security, and SNAP benefits.

The 1996 welfare reform process barred legal immigrants from Medicaid for five years after they arrive in the US. Though the legislation intended to bar only immigrants who arrived after 1996, a 2004 Health Services Research paper found the legislation may have also deterred the enrollment of legal immigrants who should have remained Medicaid eligible.

The exclusions built into the health care benefits systems, Joseph said, are aimed not only at undocumented immigrants, but people here on tourist visas, some types of student visas, and people with green cards.

In Massachusetts, health care reform was more inclusive because it covered residents regardless of documentation status, Joseph notes, but only at a certain income level. Barriers persist, she said, in accessing coverage because of technical difficulties for non-native English speakers, some of whom are also facing racial bias and the increasingly politicized status of immigrants in the United States.

During the episode, Joseph discusses her experiences navigating the health care system (5:25); the intersection between race, ethnicity, and legal status (15:00); and how Massachusetts compares to other states in health care coverage that is accessible to immigrants (26:25).