4 Barriers to Coverage Among Uninsured Individuals in Massachusetts

Uninsured individuals in the state of Massachusetts face a variety of barriers to healthcare coverage, including real and perceived eligibility gaps and a complex health insurance landscape, a report from the Blue Cross Blue Shield of Massachusetts Foundation found.

The researchers conducted a literature review on the uninsured population in Massachusetts, examined data from the American Community Survey (ACS), Current Population Survey (CPS), and Behavioral Risk Factor Surveillance System (BRFSS), created a microsimulation of public or subsidized insurance eligibility among uninsured nonelderly Bay Staters, and interviewed Massachusetts stakeholders and navigator organizations.

Young adults between the ages of 19 and 34, nonelderly men, Hispanic and non-Hispanic Black residents, noncitizens, international community members, single adults without dependent children, and individuals with limited English proficiency are more likely to be uninsured. Most uninsured individuals also did not attend college.

Additionally, 35 percent of uninsured Bay Staters had incomes below 138 percent of the federal poverty level and another 34 percent had incomes between 138 percent and 300 percent of the federal poverty level. Eight in ten had worked in the past year and a little over half had worked full-time in the past year.

The data, simulations, and interviews pointed to four main barriers to insurance in Massachusetts.

First, eligibility gaps—whether actual or perceived—can hinder residents from accessing coverage.

Among uninsured workers, only 46 percent work for employers who offer healthcare coverage. For those whose employers do offer coverage, only slightly more than a third of uninsured individuals are eligible for the employer-sponsored health plan (36 percent). Those who are not eligible or who do not receive coverage through their employers may fall into an eligibility gap.

Nearly half of all uninsured individuals were ineligible for public or subsidized coverage (48 percent). Twenty percent of all uninsured people were not eligible because they were undocumented immigrants, 18 percent were ineligible due to their income, and another 10 percent were ineligible because their employers offered a more affordable employer-sponsored health plan option.

However, over half of those who were uninsured were eligible for MassHealth, ConnectorCare, or an advance premium tax credit (APTC)-only plan.

For those who were eligible for public or subsidized health insurance and yet remained uninsured, researchers found that premiums or cost-sharing requirements could be barriers to leveraging that eligibility. Some uninsured individuals also do not see the value in health insurance, particularly when they struggle to secure appointments.

Second, language barriers were particularly difficult for uninsured immigrants to overcome.

A wide variety of languages and English proficiency were present in the uninsured population data. Those who did not have English proficiency might fail to open or respond to important health insurance notifications because they do not understand the urgency or details of this communication.

Immigrants and individuals with language barriers might not realize that the public charge rule is no longer in effect. This might result in them assuming that they are not eligible for coverage or that applying for coverage could poorly affect their chances of gaining citizenship.

Third, the complexities of the health insurance landscape complicate healthcare literacy and securing coverage.

These complexities become particularly challenging when an individual is transitioning between coverage sources. When employees lose their health plan due to a change in employment status, they may struggle to navigate the MassHealth and Health Connector sites. MassHealth enrollees who lose Medicaid eligibility might not receive notifications about Health Connector eligibility.

When an individual is unable to navigate that transition between healthcare coverage sources, they are likely to lose coverage and remain uninsured.

Finally, administrative processes can get in the way of individuals who are eligible for coverage through the state.

Application and verification requirements can overwhelm enrollees, particularly when enrolling in a Health Connector plan. Additionally, these processes rely on digital tools, internet access, and email access to secure health insurance coverage. Uninsured individuals are more likely to lack internet or computer access than the general Massachusetts population.

The use of mail as a way to share notices is also problematic for the uninsured population since they are more likely to have moved in the past year.

“In addition to problems receiving mailed notices, some MassHealth members are unfamiliar with the redetermination and renewal process, which is complex and can be difficult even for people who are familiar with it,” the report noted.

“Members may not realize they need to update and return renewal forms and send additional verification documents, and the excessive volume and complexity of mailed information can lead them to overlook important notices and requests.99 Members also risk disenrollment if they do not report job or income changes or they do not respond to requests for information about job or income changes during the year.”

Many uninsured individuals would benefit from receiving assistance and the state does offer in-person resources. However, many uninsured individuals are not aware of their assistance options.

As Massachusetts seeks to  improve its uninsurance rate the state may need to enact policy changes to address the specific barriers that uninsured populations face.