A recent study in the New England Journal of Medicine takes a close look at the remaining uninsured in Massachusetts and wonders what can be done about them.
The study, authored by John Graves and Katherine Swartz, begins by noting –
It is estimated that between 2006 and 2009, the proportion of low-income Massachusetts adults who lacked insurance coverage decreased by one sixth, while the proportion in similar states barely changed — a substantial achievement by any measure.
Well, not really. A reduction of one-sixth doesn’t seem like much of a whoop given the amount of money and attention that has been spent on this program.
But that isn’t the primary point of the article. The authors try to drill down further to understand what is keeping the other five-sixths from getting coverage. To do this, they divide the uninsured into three groups based on how long they are without coverage: (1) Three months or less; (2) Four to twenty-four months; and, (3) Longer than 24 months. They find the greatest effect was on the middle group — those uninsured for from 4 to 24 months. The other two groups were not affected at all.
It is fairly obvious why the first group was not affected. When people take a new job they are likely to have a short period of time before they begin working and the new employer updates payroll information and gets the new employee on the policy. Outside of having individual ownership of coverage, it is hard to see how this will ever change. As long as we have an employer-based system, changes in employment will always involve a brief interruption in coverage.
The real concern is the long-term uninsured. The authors write –
…the percentage of Massachusetts adults who were uninsured for longer than 24 months after the reform (26.7%) was nearly identical to the percentage of long-term uninsured in the other states (27.4%)
Hmmm, why would this be? Aren’t these the people Massachusetts was targeting? Wasn’t that the primary purpose of all the hoopla? The authors offer an explanation –
One reason that reforms might not have helped people who were uninsured for long spells is that anyone eligible for employer-sponsored insurance is ineligible for Commonwealth Care, even if the person is exempt from the mandate to obtain coverage because his or her share of the employer-sponsored insurance is unaffordable.
This seems an improbable explanation. They are supposing that all of these people are working for employers who offer coverage, but don’t accept the offer because it is unaffordable. The authors don’t support their supposition by, say, asking the people affected. Indeed, they don’t offer any evidence that these people are actually working at a regular job, let alone one that offers health insurance coverage.
I would offer an alternative explanation, one that I discussed in more detail here. There is some not-small number of people who can’t cope with insurance. To them it is clumsy and complicated, and in some cases they would prefer to be unknown to the authorities. They make money in irregular ways and would be extremely wary of a government agency that asks about their sources of income to see if they qualify for a subsidy. They are perfectly happy to go the hospital ER when they need care, or to borrow a friend’s insurance card.
These folks have no interest in insurance and will not sign up for it no matter how many academics and bureaucrats implore them to do so. This is part of what it means to live in a free society.