This survey of uninsured patients seen in a major safety net hospital ED describes some reasons why residents remain uninsured in Massachusetts four years after passage of health reform. Lack of health insurance was rarely voluntary. Despite a third of patients reporting at least one chronic medical condition, 80.9% had been uninsured for more than a year. The uninsured were mostly working poor, but only 25% had access to ESI. The vast majority of patients reported being uninsured because of a loss of insurance (predominantly from job loss or policy cancellation) or because insurance was unaffordable. Only 5.6% of our sample said they were uninsured because they didn’t think they needed insurance, suggesting few “free riders.”
We found that half of the uninsured worked for employers other than themselves, but only half of these worked for an employer who offered insurance. Of the uninsured that worked for an employer, half worked for a small firm (≤ 10 employees), exempt from the requirement to offer insurance. These findings imply that the exemption for small firms may be making ESI unavailable to those least able to find alternative sources of coverage. In addition, the current penalty for larger firms not offering ESI—$295 per full time employee—may be too low to encourage employer participation and thus ESI availability.
The finding that some of the working uninsured had access to ESI but declined it suggests that for many, the available ESI is out of reach financially. This is not surprising, since the state requires that an employer cover only 20% of an annual family premium or 33% of an annual individual premium. Recent data suggest that annual increases in medical insurance costs are being increasingly shifted from employers to their employees with ESI.16
This could lead to even lower uptake rates for ESI in the future.
Irrespective of employment status, more than 85% of this uninsured sample had incomes that were low enough that they should have qualified for state subsidized insurance (either Medicaid or Commonwealth Care). Why, then, were these patients uninsured? Nearly a third of our cohort (29.9%) reported being uninsured because they could not afford insurance, suggesting that for some working poor, even heavily subsidized insurance premiums may be unaffordable. Although the Connector is charged with ensuring that adequate and affordable insurance options are available, the rising cost of healthcare has made this difficult. Nearly three-quarters of HSN patients were foreign-born, suggesting that a high proportion of these patients may be ineligible for state subsidized insurance on the basis of their legal immigration status.
Surprisingly, over a third of the sample reported “loss of insurance” as the reason for being uninsured at the time of the survey. For subsidized insurance plans, yearly re-enrollment is required to maintain coverage and the state mails re-enrollment forms to enrollees yearly. However, if completed forms are not received by the state within 10 days, the policy is terminated. For low-income residents, who often experience substantial housing instability in the expensive Boston area, these stringent re-enrollment policies could contribute to unnecessary loss of insurance for eligible residents. In addition, even a small increase in income may disqualify residents for income-based subsidized insurance.
It is also possible that patients who may have been eligible for subsidized insurance by income criteria may have been ineligible due to immigration status requirements. A limitation of our study is that we did not ask about citizenship or legal status directly (due to concerns about human subject protections) and thus cannot determine which respondents were uninsured because of ineligibility on the basis of legal status. While we found that 59.3% of the total uninsured patients in our sample were born outside the United States, three-quarters of our sample answered the survey in English, suggesting that this is not predominantly a population of recent immigrants.
We found significant demographic differences between the uninsured and the privately insured patients in our sample; namely, the uninsured were more likely to be non-white, low income, non-English speaking and have lower educational attainment. However, with the exception of more foreign-born patients among the uninsured, our uninsured patients resembled those insured by Medicaid and Commonwealth Care, the major forms of insurance gained under the reform. This suggests that at least in part, the reform failed to fully reach the demographic groups it targeted and emphasizes the fragility of a system requiring voluntary uptake, periodic renewal, dependence on employment and cost-sharing.
Two-thirds of uninsured patients in our sample (65.7%) were aware of the reform law’s individual mandate. Half of our sample (48.6%) had responded to the mandate by trying to get insurance, but were unable to find insurance they could afford. This may explain why only 31.5% of our uninsured sample thought the reform had been good for Massachusetts, compared to the support of 67% reported for unselected nonelderly adults surveyed state-wide, which is more similar to the support for the reform we found among our privately insured patients (53.6%).4
The major limitation of our study is that the sample is drawn from a single safety-net ED. The uninsured are more likely to seek care in safety-net institutions, so this strategy allowed us to locate the uninsured efficiently, to obtain a high response rate, and to focus our investigation on persons actually requiring medical care. Moreover, our methods allowed us access to members of marginalized groups such as the homeless, the marginally housed, undocumented immigrants and linguistic minorities – groups that may be both unable to obtain health coverage and difficult to sample in phone, mail, and even neighborhood-based surveys. Comparison to neighborhood-based American Community Survey data on the uninsured in Massachusetts suggests that our ED-based sample may over-represent non-white and very poor (<150% FPL) individuals, but in terms of age, education level and employment status, does not differ significantly from the state’s uninsured.17
Another limitation of our study is that it was conducted at a single point in time. This limits our ability to understand the temporal changes in factors contributing to uninsurance, something that is also important when setting policy designed to promote continuous coverage.
Our findings suggest that several modifications of health care reform in Massachusetts could further expand insurance coverage. Employer sponsored coverage could be expanded by increasing incentives for more employers to offer insurance to employees and by increasing the proportion of premiums employers pay for employees, which would increase the proportion of low-income employees who could afford their employer-sponsored insurance. Our study suggests that the state could reexamine the affordability guidelines for state subsidized insurance; reducing premium cost sharing for low-income residents would likely increase the proportion of eligible residents actually able to afford subsidized insurance. Reducing the stringency of the enrollment process could also increase the chances that low-income residents will obtain—and retain—insurance. Our study illustrates some of the ways in which a piecemeal insurance coverage system leads to persistent uninsurance. An alternative for Massachusetts would be to adopt a more comprehensive reform guaranteeing coverage to all residents without eligibility restrictions.
Although many thought the Massachusetts health reform would eliminate or substantially reduce the need for a safety net by providing universal insurance that could be used with any provider, our study shows that under the current reform, patients continue to fall through the cracks of the insurance system. Until the barriers to universal coverage that we identify here are addressed, safety-net hospitals will remain necessary in Massachusetts to provide care for those left uninsured who can be turned away from non-safety-net institutions. Safety-net institutions will continue to be an important source of care for undocumented immigrants who are explicitly left out of health care reform.
Whether such modifications are financially or politically feasible in the current political and fiscal climate is debatable. However, because the uninsured experience both worse health outcomes across a broad range of medical conditions as well as higher mortality,18,19
preventing residents from falling through the cracks of the reformed health coverage system should be a high priority.