Stratification and Universiality: Immigrants and barriers to coverage in Massechusetts

Massachusetts became the first state to implement universal healthcare coverage in a law called Chapter 58.

• 2006
• income eligible residents, regardless of their legal status, could gain subsidized health coverage
• used to craft the 2010 ACA
• But immigrants were still less likely to be covered through the policy
• undocumented status
• difficulty of enrollment
• inability to afford premiums and copays

CHAPTER 58: Impact on Immigrants

• Policy (brought coverage up to 97% when first implemented)
• individual mandate requiring all residents to acquire coverage
• Medicaid expansion to cover low income residents
• Insurance exchange where private companies could offer coverage to middle and higher income residents 
• Employer mandate: requires large companies to provide coverage for their employees
• State maintained its preexisting safety net system primarily funded by state hospitals
• HSN- provided primary care for those who remained uninsured
• 400% of federal poverty level
• offered at 160 specially designated healthcare facilities in Mass
• MassHealth (state medicaid) Had to have 5 years legal residency (LPR) or be legal US citizens and make up to 200% of poverty level
• Commonwealth Care- provided subsidies for middle income LPRs without 5 years residency who are intelligible for medicaid and have to purchase private insurance.
• Remaining challenges elaborated on in this article
• cost containment
• low income residents receiving less care
• 1 in 5 adults being denied care because Dr didn't take their insurance
• Ethno-racial minorities and those with poor health still remain underinsured, utilize healthcare less frequently, and are unable to afford coverage or out of pocket costs
• remaining uninsured
• unstable job status
• undocumented
• fluctuating income
• Impact of Recession
• HSN funds were reduced
• reduced coverage for 40,000 short term LPRs (commonwealth care) to a cheaper program that was only accepted at hospitals outside of Boston
• 2012- law suit reinstated the CC

Immigrant Barriers to Healthcare (illustrate immigrants marginality when writing and implementing healthcare policy)

• Immigration related barriers
• documentation status
• male immigrants were less likely to have coverage if they were always working (time)
• difficulty producing eligibility information for coverage (re)enrollment
• proof of income (no paystubs in the informal economy)
• state residency (share a space rather than have their name on a lease)
• citizenship status (undocumented or LPR non citizen, daca) - required for MassHealth
• Non-English proficiency
• could not understand forms for enrollment or re-enrollment processes
• Immigration enforcement
• many were afraid to seek coverage for fear of deportation
• May overcome fear and bureaucratic barriers only to find that the "in transit" aspect of healthcare risked deportation
• Some immigrants were unaware of Chapter 58 entirely
• Lack of knowledge about what services could be used with their coverage (most had HSN)
• the available of a social network for guidance may correct this
• Bureaucratic barriers
• "Bureaucratic disentanglement" -
• forms forms forms 
• rule changes
• lack of clear and accessible information
• Healthcare system barriers
• specialty care unavailable at HSN locations
• dont understand the referral system
• dont understand the difference between copays and deductibles or ER costs
• PREFER to go to the ER because no copays--- higher healthcare costs for everyone