Health law uncertainties
PEOPLE GATHERED in two Boston churches this week to discuss healthcare had no idea of how the new state law will affect them. Neither does the board of the Commonwealth Health Insurance Connector, the public authority that will devise the new insurance policies, which met for the first time last week.
But that uncertainty is to be expected given that no state has ever tried to do what Massachusetts is undertaking -- to insure most of its residents by compelling them to get coverage. If the law is implemented well and adequately financed, it will also provide lasting benefits to working people struggling to get by in this expensive state.
The Greater Boston Interfaith Organization, a coalition of religious congregations, unions, and social service agencies, organized the meetings, which were held this week at Church on the Advent on Beacon Hill and the New Jerusalem Evangelical Baptist Church in Mattapan.
Cheri Andes, the GBIO organizer, told participants the good news first -- that, assuming the federal government agrees, the Medicaid insurance program for poor people will be expanded to include dental coverage and eyeglass benefits. In addition, 15,000 on waiting lists, many of them homeless, will be enrolled, and 27,000 children will become eligible for benefits. The dental and eyeglass benefits were cut during the recession. And the expansions of coverage are long overdue for people who are poor and need health insurance. Everyone in the state should be proud that the Legislature authorized these improvements.
But most people at the church meetings were employed and earning too much to be eligible for Medicaid. For them, Andes didn't have answers, but she had questions: What was their income and how much did they think they could afford to pay for health insurance? At the Church of the Advent, the 14 people in attendance were young and college educated. One thought $200, one thought $80, and several considered $50 a month, but one, who earned $960 a month, thought nothing at all. ``If forced to pay anymore," the anonymous respondent wrote, ``it will have to go on my credit card, which I am already behind on payments."
At the evangelical church, the 12 people in attendance, all of them from Haiti, were on tighter budgets. ``I am very overdrawn," one wrote. ``How come I could pay for insurance?" Many thought that they could spare only $5 a week.
Jon Kingsdale, the new executive director of the Connector, has worked for years as a vice president at Tufts Health Plan, but in his new job he'll have to focus on a difficult-to-insure population -- working people earning $60,000 a year or less. The law does require subsidies for people earning up to 300 percent of the poverty line -- $29,399 for a single person and $49,799 for a family of three. But preliminary calculations from the state suggest that people at 300 percent will still be expected to pay $140 a month and after that the subsidies go away. The Connector and the Legislature need to make sure that these people are not crippled financially by a law intended to safeguard their health.
One way to control costs is to limit benefits. The Connector may be tempted to endorse high- deductible plans called Health Savings Accounts, which require that people pay for routine medical expenses out of pocket. That's a recipe for financial hardship for anyone with a limited income and a chronic condition . Newly insured people, like everybody else with coverage, deserve policies that encourage them to get preventive care and deal with chronic illness before they require extended stays in the hospital.
At the initial meeting of the Connector this week, Brian Wheelan, assistant state director of Medicaid, suggested that one way to keep costs down is to funnel people to hospitals that offer low costs. That's an idea worth exploring. But if the Connector pursues this option, it needs to make sure that the hospitals provide high-quality care, and that they are not too far away from the people they would be serving. Limiting the number of providers should not be a pretext for rationing care by forcing patients to travel long distances to get it.
``It's my third day on the job and I am a staff of one," Kingsdale said last week. He's working hard to get support staff, and he'll have to hurry. The law sets an Oct. 1 deadline for establishing insurance plans aimed at those getting the subsidies, a Dec. 1 deadline to define what constitutes affordable policies for people making more than 300 percent of the poverty limit, and a July 1, 2007, start for the individual mandate, by which everyone in Massachusetts is required to buy insurance.
Despite the law, coverage for everyone is not assured. The Connector might decide policies just can't be made affordable. Individuals can file appeals if they consider the Connector-approved policies too costly. As one person at the Church of the Advent said, ``I don't like the idea of somebody deciding this for me."
Yet only 10 percent of the people in Massachusetts lack insurance. In Mattapan, despite all their obligations and limited incomes, nine of the 12 people had coverage, with the cost defrayed by Medicaid or their employer. Health insurance is considered a necessity of life by most people in the state. With the help of the Legislature and the prodding of the GBIO and other activists, the Connector has to marshal the resources and find the right combination of affordability and comprehensiveness to bring that last half-million under the protection of a good health plan.
