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:  “When 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 authorities.”

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 care. 

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.

Additionally, 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.