Why are so many people still uninsured?

A recent study sponsored by the University of Massachusetts Medical School and Blue Cross Blue Shield Foundation asked that very question.  Although the state’s individual mandate became effective in 2006, somewhere between 3 percent and 5 percent of Massachusetts residents were uninsured in 2015, about 200,000 people.

Massachusetts has the lowest rate of uninsurance in the United States at 3 percent. In contrast, the national average as of mid-2014 was 12.2 percent. It is noteworthy that the uninsurance rate in Massachusetts has not decreased since 2008. Actually, according to the study, the Massachusetts uninsurance rate has grown from 2.6 percent in 2008 to 3.7 percent in 2015.

The study authors interviewed 33 individuals who were uninsured in July 2015 to ask them why they became uninsured, why they were still uninsured, and what would help them to obtain insurance.

There were several reasons that people were uninsured:

  • loss of employer-sponsored insurance (ESI);
  • loss of eligibility for Medicaid;
  • expense of available ESI; and
  • loss of eligibility for subsidized insurance

There also were several common obstacles to becoming insured:

  • the materials were hard to understand (this was especially true for indivduals whose primary language was not English);
  • it was difficult to reach someone who could help, navigators and assisters were not necessarily available during the hours that the uninsured individuals could go for help; and
  • there was no one available to help who spoke the individual’s language.

Some individuals chose not to apply for insurance because they were healthy and did not see a need for it. Some also were satisfied with the health care that was available to them at free clinics. But most of the uninsured believed they needed insurance and preferred to have it.

Some tried to apply but could not complete the application process. Others were afraid that applying would endanger their immigration status or that of a family member. Still, the most important obstacle was financial. Even if they were eligible for subsidies, many felt they simply could not afford coverage. The existence of penalties did not influence many who chose to remain uninsured. Some said that the penalties were less expensive than insurance. When asked what would make it easier for them to become uninsured, the individuals surveyed wanted more in-person assistance to be available. The availability of assisters who spoke their language was very important to them.

The authors found that the uninsured are a diverse group, and no single outreach strategy was likely to work for everyone. It is noteworthy that there is no “coverage gap” in Massachusetts because the state expanded Medicaid. In other states, such as Texas, that have not expanded Medicaid, the unavailability of assistance is an additional obstacle.