Are You Uninsured If You Have Health Insurance But Can’t Access or Afford Care?


Health care reform
in the Commonwealth of Massachusetts was passed in April 2006 with the goal of dramatically
expanding access to affordable health insurance for Massachusetts residents.  This is the same goal articulated in
the U.S. Senate and House health care reform bills—both of which are designed to
reduce the number of people without insurance in this country.

As the national debate about the content of these bills continues, one question remains:  Are you considered uninsured if you have health
insurance but you can’t access care or afford it?

In a report
recently released by Ibis Reproductive Health and the Massachusetts Department
of Public Health Family Planning Program researchers found that health care
reform in Massachusetts has accomplished much of what it set out to.  On the whole, the low-income women and family
planning providers interviewed for the study said that access to both
preventive care and general reproductive health care has increased for many
low-income women throughout the Commonwealth.  As one health care provider quoted in the report said, “When
people have health care, they’ll use it.”

However, the
report also details a number of challenges that low-income women face in
accessing health care under reform in Massachusetts, challenges that may soon
confront the nation. 

Many of the low-income
women interviewed said that it was difficult for them to access health services
due to a long list of forms and procedures required to prove and maintain
eligibility for the subsidized health insurance plans available under reform.  Once on the plans, many were
frequently, and unnecessarily, pushed on and off the plans for which they
qualify.  Health care formularies
under the subsidized plans were described as hopeless to decode and the list of
providers accepting their health insurance impossible to decipher, and rather
short.  Some women also struggled
to afford their monthly medications such as contraception and prescriptions
needed for chronic conditions. 

In addition, the
study team also found that health care for many women has not improved or has
gotten worse since reform.  In the
Commonwealth, immigrants, young women, those with unstable employment, and
those experiencing common life changes face a multitude of challenges in
accessing care under reform. 

A family
planning provider quoted in the report explained that many immigrants were no
longer seeking care at her facility:
it became mandated for individuals to have health insurance, people were afraid
to come to medical facilities because they were under the assumption that if
they didn’t have health insurance they were going to be reported to the

Young women,
though they may be covered under a parent’s insurance, may be unable to access
reproductive health care confidentially and may therefore choose to forego

Women with
variable employment often move rapidly in and out of eligibility for subsidized
plans depending on changes in their income.  Each of these changes is accompanied by a slew of paperwork
to prove a woman’s low-income status.  Also, women experiencing common life changes such as
pregnancy, starting or finishing college, or moving reported it was difficult
to keep up with the paperwork mailed to them that was required to document
eligibility for subsidized care. 

One of the
lessons learned from the Massachusetts experiment for those working on national
reform is that the focus cannot only be on what services are included under
reform and for whom they are available, but on how reform is rolled out and
whether those the new system is intended to serve are able to access and use
it.  National health care reform will
likely have much in common with the Massachusetts model.  Based on what we have learned here, it
will be imperative for national policymakers to simplify enrollment and
re-certification procedures for those eligible to receive subsidized health
insurance .  It will also be critical
to make sure that populations excluded from health care reform, as well as
those with insurance who cannot afford copays and prescriptions, even with
federal subsidies, are able to access health services.

multiple strategies should be used to help ensure that the initial uptake and
administration of health care plans under reform run smoothly, and that clients
and health care providers can access the information they need.  This could include making sure that
health care providers get training and up-to-date information about new health
plans offered through an exchange or public option.  In addition, we must make sure that consumers are educated about
what services are covered under their insurance and know how to maintain and
prove eligibility for subsidized insurance.

Without a detailed
and realistic plan for  how national
health care reform will be implemented, many low-income women and men will fall
through the cracks of reform and be left with an insurance plan that they can neither
access nor afford.   

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  • jodi-jacobson

    I think your research is excellent and so timely.

    All of this underscores for me several critical points.  One is that passing a piece of legislation is not an endpoint.  It is a beginning, and the devil in the details of how to make law into policy into programs that actually work for people is a hugely important and often overlooked aspect of this work. 

    Another issue is how critical accountablity work–whether research or policy analysis–is to making sure laws and policies function and are accountable.

    And a third is a sense of disbelief:  Part of the problem of our health care system today is in fact what you have described above, only these problems are deeply rooted in private sector plans  as much as they are in government plans like Medicaid and Medicare…eligibility, physican referrals, formularies, paperwork, paperwork, paperwork…and indecipherable materials about your own health policy.  So it seems like health reform in Mass did not so much create as fail to alleviate and perhaps make worse what already exists.

    For example, i understand the need for eligility requirements but we seem to obsess so much that someone might get "somethin’ for nothin’" (e,g, actual health care!!) that we waste god knows how much economic productivity and lost time in paperwork…..all at the expense of the individual least able to afford those commodities.

    To me, both Massachusetts and this country have an opportunity to create an incredibly user-friendly easy to decipher, multi-reference, multi-language online tool, and a phone line for the state and federal level so that people can easily access their plans and care, so they can apply and get expeditious responses, and so forth.

    These tools would have to be backed up by a) adequate staffing by people trained not to obstruct as i feel many private insurers now do, but to facilitate the plans and the care people need; b) easy access to and training for use of computers that everyone (including with those who do not have and can not afford computers at home) can use whether at libraries or in some public spaces) c) a serious focus on the aspects of implemenation as you have so clearly laid out.

    We have the brainpower and the technology to do these things well, we need to go to communities and ask them what their needs are and how we can meet them, not devise some doomed hi-tech unusable and paper heavy program.

    Otherwise, we can legislate ourselves to death and end up with these same barriers, and fail to solve the core problem.


    Best, Jodi jacobson

  • catseye71352

    If you can’t see a doctor without an outrageous copay, YOU DON’T HAVE INSURANCE COVERAGE

    Catseye  ( (|) )

  • crowepps

    Anyone else notice that the policy discussion originally started out as how to provide ‘access to medical care’ but then quickly slid into how to provide ‘access to insurance’? Insurance is not health care. Insurance is a way of equalizing the costs of health care by widely sharing the load. The overhead costs of the insurance company directly reduce, penny for penny, the money available to pay for medical care. When insurance is set up as ‘for profit’, that profit also reduces, penny for penny, the money available to pay for medical care.