NEW BEDFORD - Need spills out of hardscrabble bars in this corner of the state. The closing of textile mills has left many residents jobless, while the seasonal nature of the fishing industry contributes to the lowest rate of health insurance coverage in Massachusetts.
More than 12,000 people sought charity care at the region's hospitals in the last 18 months, and free or subsidized health insurance would seem to be an easy sell. But less than one-third of those 12,000 low-income people have signed up, despite aggressive efforts to promote the state's insurance programs.
The problem highlights the challenge Massachusetts faces as it tries to reach its landmark goal of near-universal coverage. Across the state, tens of thousands of people believed eligible for subsidized insurance have not enrolled, even though they will face penalties if they don't have coverage by Dec. 31.
Fear of any contact with the government is a big roadblock in the large immigrant communities here and elsewhere in Massachusetts, even among those who are legal residents, say health outreach workers. And some longtime residents down on their luck are too proud to apply for state aid.
For some, health insurance is pushed to the back burner by the more pressing needs of food and shelter, according to a survey by the Blue Cross Blue Shield of Massachusetts Foundation.
Still others have missed the state's multimillion-dollar publicity barrage, find it too hard to thread their way through the sign-up process, or don't want to pay for care they have previously received for free.
"A lot more work needs to be done when it comes to the hard-to-reach population," said Helena Marques, executive director of the Immigrant Assistance Center in New Bedford, which is among the agencies working to sign people up.
Rasclot Paulet would probably qualify for a full subsidy, but last week he wasn't even aware there was a free state insurance program. "I haven't got no word, no mail from anybody," he said, taking a break from handing out cable company leaflets at the bus station.
At 19, Paulet is homeless and in need of regular healthcare for asthma. A thick, 3-inch scar on his chest is a constant reminder of the dangers of his past life, which once landed him in jail. He says he would like to apply for insurance, but worries that the lack of identification papers will pose the same problem he has faced getting other social services.
"I need a birth certificate, but they can't mail it to you if you don't have an address," he said, mentioning just one of the documents he needs. Nor can he turn to his parents for help. "My father's in jail, and my mother is dead."
This month, the state is redoubling its outreach efforts, using both a stick and a carrot. Warning letters went out to 45,000 people who used the state's free-care system last year and who have ignored two previous state mailings. The letter warns individuals of the impending $219 tax penalty if they remain uninsured and tells them that they will no longer qualify for free care. (Hospitals have said they will not turn away needy patients.)
The state is also holding 10 sign-up events in some communities, including New Bedford, in conjunction with local agencies and politicians. Previously, it had handed out more than 2 million fliers about new insurance options, in English and 10 other languages, at stores and health centers.
In addition, individual outreach agencies are trying tactics many think will be more effective, working through churches, health centers, and schools. The Blue Cross foundation is funding some of these efforts, targeting the reasons people aren't applying. Many agencies also hope to get small state grants, which are expected to be awarded in the next few weeks.
"We're finding that it takes one-on-one explanations from people that they trust in their community," said Brian Rosman, research director for Health Care for All, an advocacy group.
So far, the state has had the most success in insuring the lowest-income people, those with incomes below about $15,000, who can get free coverage. More than 100,000 people are signed up for full subsidies in the Commonwealth Care program, including many who were automatically enrolled. This is well above the enrollment that the state projected in this category. Also, about 50,000 additional low-income residents have enrolled in the free state Medicaid program, which covers mothers with young children and certain other groups.
But getting people with a little more income to pay even small premiums under the partially subsidized arm of Commonwealth Care has been a harder sell. Of an estimated 100,000 eligible residents, only 25,000 are enrolled.
When the law passed last year requiring nearly everyone to have insurance, there were an estimated 500,000 people without healthcare coverage.
If a lot of people remain uninsured, costs could rise for both the state and hospitals. The state is counting on comprehensive enrollment so that the premiums paid by healthy people can help subsidize those who are sicker. Hospitals are counting on seeing fewer uninsured patients in their emergency rooms.
Gabriela Medeiros and her husband, Jose, had been getting state-paid free care at a local hospital until their incomes crept up enough that the state imposed a sizable deductible. Then they racked up thousands of dollars in bills that they are slowly trying to pay off.
"Middle class hurts," she said. Medeiros is a secretary for an auto body shop in Dartmouth that does not offer health insurance. Her husband is a self-employed mason.
A state mailing alerted them to the possibility of subsidized insurance, but they stalled. "I was afraid they were going to tell me it's going to cost $600 or $700 a month," she said. "$600 or $700 is hard when you're paying a mortgage."
In fact, if they qualify, the subsidized premium for the couple could be as low as $210 a month.
The Medeiroses plan to seek help through the Immigrant Assistance Center, a nonprofit organization in New Bedford founded by Portuguese immigrants to help their community, as well as those from other backgrounds. The center works with local churches and uses ethnic radio and newspapers to tell people about health insurance options, but has not had the funding to devote someone full time to this outreach, said Marques, the center director.
"The number one reason immigrants are not signing up is fear," she said. "It's a government system. They're afraid that someone is going to alert immigration officials."
Many legal immigrants, she said, recall that people who got public assistance in the mid-1990s faced harsh questions when they sought citizenship because they were considered "an expense to the state." Marques said she repeatedly has to assure immigrants that getting subsidized insurance will not count against them in the citizenship process.
Outreach workers at Southcoast Health System, which runs hospitals in New Bedford, Fall River, and Wareham, are also fighting an uphill battle to get people to apply for insurance. Three staff members spend every day on the phone trying to contact patients who received free care, said Beth Sylvia, director of patient access. Financial counselors at each hospital help people navigate the lengthy application and documentation process.
"We're calling 50 to 60 patients a day," she said. "If we get two to three patients to follow up to completion, that's a good day."
In the last year, they have called 12,200 people, but only 3,800 have enrolled.
Jarrett Barrios, president of the Blue Cross Foundation, says the outreach effort needs to "move into the trenches" to address more directly the reasons that make people choose not to apply.
"That choice jeopardizes not only their own health, but may jeopardize the entire project of health reform," he said.
Alice Dembner can be reached at firstname.lastname@example.org.