^{Posted on August 31, 2007}

The dark side of healthcare reform

By Benjamin Day
The Boston Globe
August 30, 2007

AFTER EXTENDING healthcare coverage to more than 150,000 previously uninsured residents over the past year, Massachusetts health reform took a turn for the worse this month with the Patrick administration’s proposal to limit the state’s Free Care Pool.

The Free Care Pool exists to catch those who fall through the cracks of both private and public insurance programs, by reimbursing hospitals and health centers that treat the uninsured without any of the cost barriers — premiums, copayments, deductibles — that leave low-income patients with medical debt, or worse, untreated illnesses and conditions. The administration’s reforms would refuse eligibility for this safety net to everyone who is eligible for the state’s subsidized health plan, Commonwealth Care, along with anyone offered “affordable” insurance by their employer. The proposal would also, for the first time ever, impose cost sharing — deductibles and copayments — on many of the exclusively low-income patients who rely on the pool for medical care they can receive nowhere else.

In public hearings and consultative sessions hosted by the administration, not a single organization representing Massachusetts patients or residents agreed with this change. What rapidly emerged was a chorus of grassroots protest from legal advocates, patient support groups, labor, communities of faith, policy experts, doctors, hospitals, and health centers. It is easy to understand why Governor Patrick’s move to hobble the health safety net lacks a popular base of support: Last year, more than 450,000 people benefited from Free Care Pool coverage.

Why would Patrick, under the guise of a law designed to expand access to healthcare for everyone, cripple the state’s only program that guarantees that low-income, uninsured residents have a place to land when all else fails? The answer from administration officials is this: a safety net that is too effective at catching people when they fall through the cracks is incompatible with the the state’s new health plans. Almost all of those who have been added to the healthcare rolls under the reform law have come in under fully subsidized, free-coverage plans that don’t require premium payments. The partially subsidized plans, on the other hand, as well as those plans residents must purchase at full cost, haven’t exactly been flying off the shelves.

This is clear evidence that the standards for what people can afford to pay under the new law are wildly unrealistic. But state officials implementing the law argue that the existence of a working safety net may be discouraging enrollment. Commonwealth Care representatives have commented publicly that the Free Care Pool must be made less attractive.

There is a long and unfortunate history to this line of thinking, which has led to the erosion and, at times, the vilification of our economic safety net institutions. From the Work Relief programs of the Great Depression through Welfare to Workfare, attempts to erode income security have been proposed as a way to corral the unemployed into the workforce. In the United States, the only developed nation without a national universal health plan, the health safety net is targeted as a means of corralling the uninsured into traditional insurance plans.

There is little evidence that eroding safety net programs actually helps improve participation in the labor market or the healthcare market. This does, however, succeed in punishing the poor, throwing low-income communities back on their own resources, and increasing the stigma upon safety net recipients. In the case of the new health law, this is a particularly meaningless and insulting exercise, as the law itself provides stiff financial penalties for any who are deemed able to afford health insurance but fail to enroll in a public or a private plan.

In 2008, the state penalty for being uninsured will be more than $1,000 per year, exceeding the fines for virtually all criminal violations on the books including violation of the child labor laws (a $50 fine) and domestic assault (a maximum $1,000 fine). And a person will still be uninsured after paying it.

The nation today is looking to Massachusetts. Are we as a society willing to use our neighbors’ health as an additional stick to punish them for deciding they can’t afford the state’s “affordable” premiums? I hope not.