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Patients’ Experiences Under Massachusetts Health Care Reform

Feb. 18, 2009

Massachusetts’ health reform has resulted in a significant number of individuals newly insured through state-subsidized health plans, MassHealth, or private insurance coverage. For some patients, this has improved their access to care.

Gabe: “I’m an actor and got lucky enough to get cast in the commercials for the Health Connector. I quickly signed up for a plan. Having paid $400 bucks a month before; I now only pay $220 a month. Currently, I’m receiving better benefits and have less out of pocket expenses.”

Gabe’s story reported by the Commonwealth Connector

However, for many other patients, the Massachusetts health care reform has not worked so well.

Despite the efforts of the state agency tasked with administering the reform to ensure affordable coverage, many Massachusetts residents are unable to afford the insurance options available to them.

John and Judy are in their sixties, but not yet eligible for Medicare. After their retirement, they became uninsured. They knew they needed good coverage because Judy was recovering from breast cancer and chemotherapy treatments. They thus purchased a Commonwealth Choice Gold family plan with premiums at $1,400 per month, which consumed nearly half of their $3,000 monthly income.

John and Judy’s story reported by Andrew Cohen and Carol Pryor, “In Debt But Not Indifferent: Chapter 58 and The Access Project’s Medical Debt Resolution Program.”

Yvonne is a 48-year old woman who could not afford the $91 per month premium contribution for her employer-sponsored health insurance plan. Although her income was less than 300 percent of the poverty level, she was categorically ineligible for Commonwealth Care because her employer paid more than one third of the insurance premium. Yvonne successfully applied to the Connector Authority for an affordability waiver from the individual mandate, in order to avoid the tax penalty. Although she had partial Health Safety Net coverage, the $1000 annual deductible made it difficult to access care.

Yvonne’s story reported by Andrew Cohen and Carol Pryor, “In Debt But Not Indifferent: Chapter 58 and The Access Project’s Medical Debt Resolution Program.”

Because of the cost sharing associated with the private insurance plans available under the reform, many patients cannot afford the care they need.

Nancy is a middle-aged woman who enrolled in the state’s subsidized health plan and is now very glad to have health insurance without a monthly premium. However, she still finds it difficult to keep up with the co-payments for her frequent doctors’ visits. Nancy borrows money from her children to cover those costs.

Nancy’s story reported by Andrew Cohen and Carol Pryor, “In Debt But Not Indifferent: Chapter 58 and The Access Project’s Medical Debt Resolution Program.”

Ken has diabetes and hypertension. Last year he was unemployed and MassHealth covered the full cost of his medications. He is now employed, with private insurance through his employer.  His medication deductible is now $700; after reaching the deductible, he will need to pay 20% of the cost of the medicine.  He works in retail and supports his unemployed wife and five children.  He cannot afford his insulin with his new insurance, so he has stopped it and  his hemoglobin A1C (a measure of diabetes control and a predictor of complications)  has been getting worse.

Ken’s story told to Dr. Rachel Nardin by his physician

Kathryn is a young diabetic who needs twelve prescriptions a month to stay healthy. “Under Free Care I saw doctors at Mass General and Brigham and Women’s hospital.  I had no co-payments for medications, appointments, lab tests or hospitalization… Under my Commonwealth Care Plan my routine monthly medical costs include the $110 premium, $200 for medications, a $10 appointment with my primary care doctor, and $20 for a specialist appointment.  That’s $340 per month, provided I stay well.” Upon becoming “insured,” Kathryn’s medical expenses consumed almost one-quarter of her take home pay.

Kathryn’s story collected by MassCare

Many patients, like Kathryn, who were well cared for under Massachusetts’ old system have found that the reform has reduced their access to needed care.

Anna, a middle-aged woman with two children,  suffers from post-traumatic stress disorder. Under free care, all necessary treatments were covered. Now that she is insured by a Commonwealth Care plan, she has had to forego weekly visits to her therapist and has halved her medication dosage, trying to stretch her supply of pills out to avoid the unaffordable co-payments.

Anna’s story told to MassCare by her physician.

A local clinic that cares for persons with human immunodeficiency virus (HIV) has reported three cases to the state of patients who were no longer able to obtain continuous HIV medications because they could not afford the co-payments of their frequent visits.   Starting and stopping HIV medications is dangerous to the patient, and to the community, as discontinuities in therapy can cause the HIV virus to develop resistance.   One of the patients has a highly treatable cancer, but declined chemotherapy because he could not afford co-payments for his visits. Under the state’s previous free care program, these patients had received their medications and visits without co-payments.

Story told to Dr. Rachel Nardin by physicians and staff of the HIV clinic.

The implementation of the reform, with its complicated rules and regulations that overlap with existing programs has created confusion and coverage gaps for patients.

Jane, who applied for the state’s subsidized health plan, received a letter telling her she had qualified for both Commonwealth Care and the Health Safety Net. The letter told her that if she received care under the Health Safety Net, she would have to pay a $1,900 deductible. Thinking this deductible applied to her health plan, she did not see a doctor because she thought she would have to pay the deductible first, which she could not afford.

Jane’s story reported by Andrew Cohen and Carol Pryor, “In Debt But Not Indifferent: Chapter 58 and The Access Project’s Medical Debt Resolution Program.”

Jean was unemployed and uninsured after being laid off from her finance administration job. She delayed seeking care for an injured wrist until the pain became unbearable and she had to go to the Emergency Room of a local hospital. The staff at the front-desk handed her a blurry print-out of a form to apply for MassHealth and the Health Safety Net, but it was illegible. Jean went home and waited until she received a bill before contacting the hospital about financial assistance options. Since more than 10 days had passed since she had received treatment, Jean was no longer eligible for Health Safety Net retroactive coverage.

Jean’s story reported by Andrew Cohen and Carol Pryor, “In Debt But Not Indifferent: Chapter 58 and The Access Project’s Medical Debt Resolution Program.”

The Massachusetts reform does not ensure that people can maintain continuous coverage.

Christin had a new job with a six-month waiting period before she could get coverage under her employer’s health insurance plan. Less than one month before the waiting period would have ended, she experienced severe abdominal pain from kidney stones. The treatment left her with $6,500 in hospital bills.

Christin’s story reported by Andrew Cohen and Carol Pryor, “In Debt But Not Indifferent: Chapter 58 and The Access Project’s Medical Debt Resolution Program.”

The reform leaves students especially vulnerable.

Andres was a student when doctors diagnosed him with cancer. He had university-sponsored insurance that left him with tens of thousands of dollars in hospital and doctors’ bills. As an insured person, he was eligible for six months of retroactive coverage under the Health Safety Net, which paid $28,000 of his medical bills. Hospital-based physicians wrote off an additional $8,000 in bills. Andres also appealed his insurer’s coverage denials, and his insurance ended up covering $9,800 in claims that it had previously denied. Unwilling to seek additional medical care under his current plan, Andres tried to purchase insurance, but found that as a student he was not eligible for a state subsidized health plan. However, as a student with no income, he could not afford to buy a non-subsidized plan and had to borrow money to pay for a Commonwealth Choice plan.

Andres’ story reported by Andrew Cohen and Carol Pryor, “In Debt But Not Indifferent: Chapter 58 and The Access Project’s Medical Debt Resolution Program.”

A random survey of Massachusetts’ residents affected by the reform found that half of those affected by the reform said that they had personally been hurt by it. The Massachusetts reform is not a model for the nation.

Monica had recently moved back to Massachusetts and was solicited by mail to enroll in Commonwealth Care, which she did to avoid the tax penalty for being uninsured. After leaving her full time job for part-time work so she could return to school, her income dropped by 60%. She informed the Connector of her change in income by phone but was unable to afford her insurance premiums. She received threatening notices from the Connector indicating that she would be disenrolled and thus subject to the tax penalty for uninsurance. She appealed this decision to MassHealth, which determines eligibility for Commonwealth Care.

“After a two hour hearing I was told that although MassHealth determines eligibility for Commonwealth Care, that’s where the collaboration ends.  I was also told that I should not have been eligible for Commonwealth Care as a full time student, which the Connector representative failed to mention to me when I told him of my income drop eight months earlier. The MassHealth workers had a difficult time explaining the Massachusetts model to me and when asked about the appeal process for the Connector, they looked at each other quizzically and admitted that they were not sure how to go about appealing a decision that fell under the Connector’s jurisdiction.  After so many months of dealing with inept bureaucracy, I have given serious thought to leaving Massachusetts.  I am researching graduate schools in other parts of the country- places where I will willingly pay taxes, but will not be forced to pay my hard earned money to subsidize a $12 billion dollar a year insurance industry.  The Massachusetts model is a punitive model that causes stress and worry to many residents.  I would not recommend it to anyone, nor would I want to see it implemented throughout the country.”

Monica’s story told to Dr. Rachel Nardin and reprinted with her permission.