Health care reform in the Commonwealth was designed to dramatically expand access to affordable health insurance for Massachusetts residents. Indeed, reform has reduced the already low uninsured rate in the state; in 2010 Massachusetts had the lowest rate of uninsured residents in the nation, and 97 percent of women were insured (Massachusetts Division of Health Care Finance and Policy 2010; Long et al. 2010). Despite these increases in coverage, reform is not without its challenges. Though very close to having 100 percent of residents covered by insurance, social and financial constraints caused some populations to be excluded from the benefits of reform either explicitly or by oversight.

Undocumented immigrants were explicitly left out of health care reform (though as stated above they can get some covered services through MassHealth Limited and Health Safety Net) (Health Law Advocates 2010). Further, our research shows that documented immigrants eligible for public or subsidized insurance had problems understanding what programs and services they were eligible for and as a result sometimes delayed or stopped seeking care from primary health care providers and family planning clinics.

This is disturbing because the policies and programs specific to immigrants affect a large number of people in the Commonwealth. Massachusetts has the eighth-largest proportion of immigrants (defined as persons living in the United States who were not US citizens at birth) in the United States, making up approximately 13 percent of the population in 2009 (Camarota 2007; Gryn and Larsen 2010). Latinos comprise the largest group of immigrants in Massachusetts (34 percent) and also the largest group of recently established immigrants (43 percent) who are least likely to be eligible for insurance (Clayton-Mathews, Karp, and Watanabe 2009). Indeed, recent estimates suggest that Latinos are uninsured at over twice the rate of their non-Latino counterparts (Blue Cross Blue Shield of Massachusetts Foundation 2011). Our findings suggest that this low rate of insurance coverage may be due in part to a lack of clarity about which health insurance programs immigrants are eligible to enroll in.

Our research also shows that some minors and young women were unable to use their insurance because of the difficulties of navigating a complex health care system. The life transitions that minors and young adults commonly go through appeared to affect their eligibility for insurance, rendering an already complicated system even more confusing. We also found that certain positive features of health care reform (such as young people's ability to stay on their parents' insurance until age twenty-six) may have unintended negative consequences: young people on their parents' plans cannot access health care confidentially and may forgo care as a result.

Other research confirms our findings about the specific challenges young people face as they go through multiple life changes in early adulthood that affect their insurance eligibility. Indeed, Bessett et al. (2010) found that because such transitions are often accompanied by additional paperwork and waiting periods for enrollment, young people may experience gaps in their insurance coverage.

Our findings also suggest that women living outside urban areas may have difficulty finding a health care provider who accepts one of the Commonwealth Care plans and scheduling a timely appointment with that provider. However, these findings must be viewed with caution, since most of the study participants worked or lived in urban areas, and the majority of the Massachusetts population lives in one of a number of urban areas in the state (Kaiser Family Foundation 2010).

At the same time, our findings about women living outside urban areas are supported by previous studies showing that 7 percent of the population lives in areas of the state that are medically underserved and face documented health care provider shortages; these areas tend to be outside major urban areas (Kaiser Family Foundation 2012; Rural Policy Research Institute 2009).

This study showed the specific challenges facing women with variable employment, women going through common life changes (e.g., pregnancy, marriage, starting or finishing college, leaving home), and women whose primary residences frequently change; these women were prone to regularly experiencing gaps in health insurance coverage and were often unaware of when their eligibility began or when they had been dropped by a plan. The findings are supported by evidence showing that a sizable number of people in Massachusetts frequently come on and off insurance programs. In fact, one study found that 28 percent of MassHealth enrollees experienced at least one gap in coverage during a three-year period (Seifert, Kirk, and Oakes 2010). In addition, in an average month more than twelve thousand individuals are dropped from either MassHealth or Commonwealth Care for administrative issues such as failing to return paperwork to document income or employment status (ibid.).

It also became clear that family planning providers are key health care providers for many of the populations discussed above and will continue to be critical resources for ensuring that women can access insurance and health services, both inside and outside family planning. Other analyses have confirmed this finding, showing that safety net providers, including community health centers, hospitals, and family planning providers, are critical for helping the newly insured navigate their insurance plans while also providing affordable services to those who are ineligible for subsidized plans or who are temporarily uninsured (National Association of Public Hospitals and Health Systems 2009; Gold 2009). Moreover, a recent analysis found that demand for care at safety net facilities in Massachusetts (defined as facilities that provide a significant level of care to low-income, uninsured, and vulnerable populations) continues to rise and that most clients of these facilities prefer the care they receive at these locations (Ku et al. 2011).

More research is needed to determine whether the findings from this exploratory study reflect the experience of a broader population of low-income women across Massachusetts. However, it seems clear that those populations left out of health care reform have encountered significant barriers to health care service access, barriers that may be mitigated by family planning providers.