Massachusetts Uninsured
A recent study in the New England Journal of Medicine takes a close look at the remaining uninsured in Massachusetts and wonders what can be done about them.
The study, authored by John Graves and Katherine Swartz, begins by noting –
It is estimated that between 2006 and 2009, the proportion of low-income Massachusetts adults who lacked insurance coverage decreased by one sixth, while the proportion in similar states barely changed — a substantial achievement by any measure.
Well, not really. A reduction of one-sixth doesn’t seem like much of a whoop given the amount of money and attention that has been spent on this program.
But that isn’t the primary point of the article. The authors try to drill down further to understand what is keeping the other five-sixths from getting coverage. To do this, they divide the uninsured into three groups based on how long they are without coverage: (1) Three months or less; (2) Four to twenty-four months; and, (3) Longer than 24 months. They find the greatest effect was on the middle group — those uninsured for from 4 to 24 months. The other two groups were not affected at all.
It is fairly obvious why the first group was not affected. When people take a new job they are likely to have a short period of time before they begin working and the new employer updates payroll information and gets the new employee on the policy. Outside of having individual ownership of coverage, it is hard to see how this will ever change. As long as we have an employer-based system, changes in employment will always involve a brief interruption in coverage.
The real concern is the long-term uninsured. The authors write –
…the percentage of Massachusetts adults who were uninsured for longer than 24 months after the reform (26.7%) was nearly identical to the percentage of long-term uninsured in the other states (27.4%)
Hmmm, why would this be? Aren’t these the people Massachusetts was targeting? Wasn’t that the primary purpose of all the hoopla? The authors offer an explanation –
One reason that reforms might not have helped people who were uninsured for long spells is that anyone eligible for employer-sponsored insurance is ineligible for Commonwealth Care, even if the person is exempt from the mandate to obtain coverage because his or her share of the employer-sponsored insurance is unaffordable.
This seems an improbable explanation. They are supposing that all of these people are working for employers who offer coverage, but don’t accept the offer because it is unaffordable. The authors don’t support their supposition by, say, asking the people affected. Indeed, they don’t offer any evidence that these people are actually working at a regular job, let alone one that offers health insurance coverage.
I would offer an alternative explanation, one that I discussed in more detail here. There is some not-small number of people who can’t cope with insurance. To them it is clumsy and complicated, and in some cases they would prefer to be unknown to the authorities. They make money in irregular ways and would be extremely wary of a government agency that asks about their sources of income to see if they qualify for a subsidy. They are perfectly happy to go the hospital ER when they need care, or to borrow a friend’s insurance card.
These folks have no interest in insurance and will not sign up for it no matter how many academics and bureaucrats implore them to do so. This is part of what it means to live in a free society.
Good post Greg.
“This is part of what it means to live in a free society.”
Truest thing I’ve heard all week.
You cant make people do what they dont want.
“These folks have no interest in insurance and will not sign up for it no matter how many academics and bureaucrats implore them to do so. This is part of what it means to live in a free society.”
So people who borrow a friend’s card (fraud) or who show up to the ER and then don’t pay the bill are somehow evidence of our freedom? They’re not examples of irresponsibility or criminality? They’re not foisting the cost of their irresponsibility on the insured? They’re somehow heroic for this?
Freedom has to be balanced with responsibility. I’m not sure I’d hold up insurance fraud as some kind of example of heroic libertarianism either.
A free society should also require these people to pay for all their medical care at the ER, deny service to those with bad credit, and prosecute for failure to pay.
Once society is callous enough to do that I think we’ll be truly free.
There is an additional explanation as to why the insured rate hasn’t changed for people in the “Three months or less” category. Per COBRA, they have up to 60 days to elect and an additional 45 days to pay; a total of 105 days. If someone leaves one job with coverage, but starts another within 60 days (or 105 if they want to elect coverage at day 60 then be canceled at day 105 for non-payment of the premium), then it would be irrational to COBRA unless their claims during that period exceed the premium cost. So, these people essentially had coverage if they had needed it, but appear to be uninsured.
If people, in Massachusetts or anywhere else for that matter, choose not to have insurance (at their own risk) then nobody should feel empowered to force them to get one…not the government or anyone.
Your entire post is great! However, I’m not sure I agree with this particular statement: “They are perfectly happy to go the hospital ER when they need care, or to borrow a friend’s insurance card”…Isn’t this illegal? If those unable to afford health insurance, or simply don’t want it, were allowed to use somebody else’s by simply using their insurance card…what’s the point of anyone having health insurance in the first place? Even if I can afford it, I would much rather save that money and whenever I need to see my doctor use somebody else’s insurance. Is this possible? If so, I wasn’t aware of it.
Charlotte, August, and Mark —
I’m not celebrating this behavior, simply pointing out that it exists and will always exist and there is nothing we can do about it — at least within the constraints of a free society.
Bad debt is a smaller problem as a percent of sales than shoplifting in retail stores. Retailers go to great lengths to prevent shoplifting, but it still persists. There is a way to stop it cold — search every customer on their way out of the store. That could be done but there would be a fury from the general public.
The reality is we can pass all the laws we want and nothing will stop some people from free-riding. Mandates simply never work for some percent of the population — all mandates, even tax laws and child support laws that carry a penalty of jail time.
True.
That’s a lot more uninsured than I thought would be there.
Greg: how does the study address the illegal immigrant population? They (presumably) add to the uninsured but are not eligible for provisions of the reform. I dont know whether the mandate applies to them.
Ian, good question bit the study authors don’t address it at all. They have a single focus are seem unable to consider other issues.
Thanks for the clarification Greg, you’re right. No law can ensure 100% compliance, but I think on balance the mandate would still be a net positive.