Challenges Remain in Accessing Insurance and Benefits
While most participants felt that reform increased women's access to insurance and health services, some described barriers for low-income women in using their insurance. Confusing eligibility requirements and enrollment challenges made it difficult for women to obtain and maintain insurance coverage. One woman in a Worcester, focus group described problems understanding what insurance plan she was eligible for:
They're making it as difficult as possible. Every week, I had to send paycheck stubs. I had to get documentation from my employer when I got laid off. I had to get documentation from here. I had to get documentation from there. And I wasn't eligible for this. And I wasn't eligible for that. And I wasn't eligible for the other thing.
Further, the results of our desk review and interviews with women revealed that information on the health insurance websites was difficult to wade through to determine benefits available under the plans. In addition, women found it difficult to schedule a timely appointment with a health care provider; some providers in the Commonwealth do not take any of the subsidized insurance plans, and many health care facilities have long waiting periods for new clients.
Though some women and family planning providers reported increased access to prescriptions since health care reform, barriers were also revealed. Focus group participants and providers reported that pharmacy locations were often inconvenient and that some pharmacists did not know what prescriptions were covered by the new subsidized plans. Some women were unfamiliar with how to use prescriptions, particularly for contraception, because they were used to obtaining contraception in person, on a sliding scale, and often in bulk from family planning providers. One direct service family planning provider described this challenge:
I have patients come in here that don't even know about prescriptions .... They say, “I don't have any more birth control pills.”... I say, “No you have three refills .... Your insurance only allows you to get one [pack a] month. Each month you have to go to the pharmacy and get another.”They just--they don't even know that; they're thinking that there is a problem.
Findings related to service affordability were mixed. While most women in the focus groups said that one of the primary benefits of health care reform was the affordability of services and prescriptions, many family planning providers reported that insurance-related expenses were burdensome for their clients. We believe this incongruity may be related to limitations in our focus group sample. Indeed, most of the women in our groups had incomes that qualified them to have $0-$3 co-pays for services or prescriptions. We suspect that women in different tiers of subsidized plans with co-pays of up to $22 for office visits and up to $50 for prescriptions may have different experiences with affordability.
Challenges Accessing Health Services: Immigrant Women
Health care reform in the Commonwealth excluded undocumented immigrants, who remain largely ineligible for coverage. Immigrants without legal documentation can obtain MassHealth Limited, which covers only urgent and emergency care, and Health Safety Net, which is not considered insurance coverage and is accessible only in certain settings, such as hospitals and community health centers, and only for medically necessary services (Health Law Advocates 2010). Because the Massachusetts immigrant population is largely made up Of young Latinas of reproductive age (Clayton-Mathews, Karp, and Watanabe 2009), we explored their access to services and insurance under reform. Table 4 shows that all participants in the Spanish-language focus groups identified as Latina, as did one woman in an English-language group.
We found that health care reform has spurred tremendous misinformation about the availability of health care and insurance coverage for both documented and undocumented immigrants. Four primary challenges to health care access for immigrants generally and foreign-born Latinas specifically were documented: lack of access to Spanish-language health insurance information; the inability of some immigrants to legally enroll in any type of insurance plan; fear of deportation; and unawareness of the continued availability of services at public health clinics for individuals who remain uninsured.
Family planning providers and women recognized that non-English speakers can face a multitude of barriers to accessing care, including the inability to get information about their health care plan in their native language. According to one hospital-based provider, who primarily serves clients whose first language is not English, “Notices [from insurance companies] and things that they get, [they] are not ... able to read, and then they have to bring it somewhere to have it translated.”Indeed, many Spanish-speaking participants in the focus groups described getting assistance from Spanish-speaking providers to access information about enrollment in health care plans and to read Commonwealth Care correspondence that was sent to them in English. In a Boston focus group, one woman described bringing papers she received from Commonwealth Care to a local family planning provider. She described needing to fill out the papers to verify her eligibility: “To renew the insurance contract, that's the only thing I do .... I get the papers at home and I don't open them, I bring them right to the clinic, I don't know what they do with them there, I don't take care of that, I just take them out of the mailbox and bring them to the clinic.”
Provider assistance appeared to help many Spanish-speaking women overcome the barrier of receiving insurance materials in English. Focus group participants and family planning providers voiced concerns about the reform's impact on undocumented immigrants. In particular, participants in the Spanish-language focus groups believed that health care reform had a negative impact on immigrant women's access to care because before reform it had been easy to get insurance and health care without proof of citizenship; however, women now felt that excessive documentation was required. One woman in a Lawrence group described this change: “They didn't ask ... if you were legal or illegal, they didn't ask anything .... Now, they ask everything. If you are citizen you have to show it. Before you didn't, you said ‘I'm a citizen,’ and that's it. It's really bad in that respect.”
The accumulation of these barriers led some women to stop seeking health care altogether. One Boston focus group participant described how paperwork and citizenship requirements of the health care reform have led some women in her community to stop going to doctors. She said: “So many people say, ‘Uy! I don't have papers ... so I can't go to a doctor.’ What happens?”Likewise, family planning providers expressed concern that many immigrants had stopped seeking care because they feared they would be fined or deported if it was discovered that they were undocumented and without health insurance. One family planning provider described how fear of deportation or other general legal action had been heightened since reform, and the negative fallout of the fear:
Some of our clients are undocumented .... When it became mandated for individuals to have health insurance, people were afraid to come to medical facilities because they were under the assumption that if they didn't have health insurance they were going to be reported to the authorities.
Some providers reported that women even stopped seeking care from family planning clinics where care is provided regardless of income, insurance, or immigration status and are instead “leaving the system.” One hospital-based provider summarized these challenges: “There are issues around immigrants [who] don't understand whether they can come in [to family planning clinics] .... There is that confusion .... They fall through the cracks.”
Challenges Accessing Health Services: Minors and Young Women
Because of challenges that young people commonly face in getting and keeping insurance, efforts were made in Massachusetts to ensure consistent access to insurance. Such changes included extending the age at which young adults could stay on their parents' health plan and designing health plans to meet young adults' health care needs (Health Connector n.d.). Despite these laudable efforts, we found that minors and young women faced unique challenges, specifically in accessing reproductive care.
Providers reported that though many people in the community believe young women can obtain health care through a parent's insurance, it is important to note that when using parents' insurance, a young woman may not be able access reproductive services confidentially. For those covered as dependents under their parents' plans, an explanation of benefits disclosing the services provided might be mailed to the primary insured member, usually the parent(s). A few providers mentioned seeing an increase in teens who were seeking confidential care. One family planning administrator noted that “health care reform essentially left out teenagers. Anybody who is under eighteen is not eligible for Commonwealth Care plans, so it assumes that those kids are covered under their parents' insurance, but if clients are coming to family planning and they want confidential services we are not about to bill their parents' insurance.”Participants reported that these women face challenges accessing reproductive care confidentially and often do not feel empowered to advocate for themselves when navigating a complex and sometimes bureaucratic health care system.
Providers and women also noted concerns about a slightly older population-- those young women aged 19-25 who are no longer minors but are transitioning into adulthood. Focus group participants believed that these women may be less skilled at advocating for themselves when navigating the health care system because they have traditionally relied on their parents to do so. While technically access to health insurance may have increased, it “may not actually be taken advantage of” by young women. As one Boston-based woman reported, “I feel like some other young women who are just really needing this type of health insurance to get contraceptives, if they don't know about it and they don't know how to go about these really confusing things, then [they're] not going to do it.”
Because of these challenges, women and providers feared that minors and young women choose to forgo seeking reproductive health care, even in circumstances where they may be able to obtain it confidentially through family planning providers.
Challenges Accessing Health Services: Women outside Urban Areas
The majority of study participants lived or worked in urban areas, but our limited data suggest that women living in rural areas faced more challenges accessing health care services compared with those in urban areas. Women living outside urban areas often had difficulty finding a provider who accepted their insurance plan and was accepting new clients. Distance to a pharmacy was also noted as a barrier to accessing contraception and other prescription medication. One family planning provider said she perceived relatively easy access to contraception in urban areas like Boston but that “it's a whole different ball game if you're out in the Berkshires [rural western Massachusetts] or something like that.”This was confirmed in our focus groups, as women in Boston described relatively better access to services than women in more rural areas of the Commonwealth.
Challenges Accessing Health Services: Women Facing Common Life Transitions
A theme that emerged strongly in the data is that low-income women of reproductive age face problems maintaining continuous enrollment in insurance for a number of complex reasons related to the frequent financial, social, and biological transitions that are common in their lives.
Financial transitions that affect eligibility occur among women who are laid off from their jobs, work on a part-time basis, are seasonally employed, or cannot afford their employer-sponsored health insurance, premiums, or co-pays. One family planning provider pointed out that women with variable employment also have variable income, which affects their eligibility for subsidized insurance: “We serve the Cape and Island population--and that is a very transient population, as is their work .... health insurance is following [not only] the ebb and flow of people's financial status, but also of their lives.”In addition, despite employer-sponsored insurance being strongly encouraged by reform, the recent economic crisis has magnified the problem of moving on and off coverage, because many people are losing their employment and therefore losing their access to employer-sponsored insurance. One hospital-based family planning provider described the situation:
People working may be eligible and enrolled in Commonwealth Care and then they begin working at a place that offers them health insurance and ... their employer says that they have to have that health insurance ... and so they do that and then a few months later they lose their job and now they have to reapply for insurance.
The social changes women experience, such as marriage, starting or finishing college, or moving, also play a role in their eligibility and coverage changes. Summing up all these changes, one family planning administrator noted of her client population:
They are living in very complicated periods of their lives when they are making transitions from living with their parents to living with a boyfriend or getting married or having children .... there are lots of changes and some of those changes tend to affect how things like insurance and government relate to that.
Biological changes such as pregnancy were also often mentioned as major life events that affect women's insurance eligibility. Providers reported that pregnant women may be unable to work and thus would lose their employer-sponsored insurance, while others may become eligible for certain plans based on their new status. Women in focus groups described becoming pregnant as an important change that often made them eligible for insurance. Many described “lucking out” by being pregnant at the time they were seeking insurance because it “fast-tracked” them to enrollment. However, some of these same women were surprised when they were dropped by their insurance carriers shortly after having a baby, as they only later learned that after giving birth their eligibility for insurance coverage changed.
Women going through all these common life transitions were prone to experiencing gaps in health insurance coverage and were often surprised to see how these changes affected their ability to enroll or maintain their eligibility in a plan. As one clinic manager said, “We are seeing a higher number of patients who are ... no longer insured, but they think they are .... At any given point, there are a certain number of people who are insured, but by the next day, a large proportion of those are probably uninsured again.”Similarly, many women in the focus groups said they did. not know why they were dropped from their plans and that they found it difficult to re-enroll once their coverage was terminated. After losing her job and employer-sponsored health insurance, one Boston-based woman enrolled in a Commonwealth Care plan said, “I've been kicked off twice. For me, it wasn't hard to get on; it's getting kicked off .... I'm actually dealing with that right now. It's just been really, really--it's always really confusing.”Indeed, many focus group participants described a time-intensive, paperwork-heavy process when trying to recertify their eligibility for Commonwealth Care.
Getting on and staying on an insurance plan through common life transitions caused a number of hardships for women. They reported considerable stress in managing their health insurance and an inordinate amount of time addressing eligibility problems. Women also reported waiting to see their primary health care providers until they got back on a plan, using emergency rooms to obtain routine care, or reaching out to public health clinics such as family planning providers for health care. Changes in enrollment therefore affected not only women and their families but also the health system.
