Implications for National Health Care Reform
Because national health care reform has been modeled on the Massachusetts approach, many of the successes and challenges described above are likely to arise as national implementation efforts move forward.
First, the barriers to health care experienced by both documented and undocumented immigrants in this study raise a number of concerns about the impact of the PPACA on immigrants throughout the United States. Almost 13 percent of the US population is composed of foreign-born individuals, and well over half (56 percent) of those individuals are not current US citizens (Gryn and Larsen 2010). Estimates suggest that there are 3.7 million low-income undocumented immigrants in the United States and that the majority are uninsured (Blewett 2010). This will not change under national reform; undocumented immigrants will not be able to participate in the health care exchange, with a few exceptions: income-eligible individuals will be able to receive emergency care, and states will have the option to cover prenatal care for pregnant women. Our results suggest that immigrants who do not qualify for coverage may be unaware that they can continue to get low- or reduced-cost care at safety net providers. Documented immigrants may also be confused about their eligibility for insurance or afraid to apply for it, and face challenges obtaining public or subsidized care. For these reasons, special efforts will be needed to make sure that immigrants eligible for health insurance under the PPACA are aware of their options, and those not eligible must be advised of their continued ability to access health care.
Second, it is critical to address difficulties that minors and young adults are likely to face under the PPACA. Nationally, low-income minors and young adults are at particular risk for not having insurance (Kriss et al. 2008). Though reform will probably increase insurance coverage for these individuals, it is unclear if the coverage will lead to gains in access to services because of the complexities of navigating the health insurance system and the many transitions these populations face in their lives when they may temporarily lose insurance. In addition, while health care reform will expand access to private and public health insurance for adolescents and young adults, it does not guarantee that confidential care will be available to this newly insured segment of the population. Proactively monitoring minors' and young adults' access to insurance coverage under the PPACA is warranted. Policy solutions are also needed to make certain that those insured under their parents' policies can access health services confidentially.
Third, while national reform holds the promise of greatly reducing the number of uninsured, challenges of maintaining enrollment in health plans may render the available insurance coverage largely unusable. Our results suggest that the federal requirement that insurance providers routinely recheck their clients' eligibility must be balanced with the realities of individuals' lives; the health system appears to struggle to accommodate common life transitions that affect individuals' eligibility for insurance programs as well as those that do not. Other scholars have suggested a number of ways to guarantee retention in Medicaid programs, including simplifying the forms required to verify eligibility or extending the period between eligibility checks (Seifert, Kirk, and Oakes 2010). We support these recommendations because continuous access to insurance is required for continuation of and timely access to prescription contraception as well as other health care services. In addition, reducing the volume of individuals transitioning on and off insurance plans would reduce administrative costs in the long run (ibid.).
Fourth, the accessibility of health care providers who accept insurance plans developed under national reform must also be considered. Women in our study had difficulty finding providers who accepted plans developed under Massachusetts reform. This challenge was exacerbated in rural areas but was also experienced by participants in Boston, which has what could be considered a large and established network of health care facilities. Women living in other localities throughout the nation with fewer health care providers, or with health care providers who do not accept public or subsidized health plans, may find it increasingly difficult to make health care appointments. More work is needed to document gaps in health services under national reform and to develop program solutions to ensure that those living in underserved areas can still access health care in a timely manner.
This study highlights the critical importance of integrating current safety net systems into national health care reform efforts and continuing to support those systems to meet the needs of populations who fall through the cracks or have trouble negotiating the health care system. The perception that there will be nearly universal insurance coverage under national health care reform presents an important communication challenge for safety net providers, which must be able to justify their relevance in the post-health care reform environment. Our results suggest that safety net providers will continue to deliver care to those who remain uninsured or underinsured, usually with the support of public funds. The specific role of family planning providers in this context needs to be emphasized in light of recent attempts to cut funding to Planned Parenthood, one of the nation's largest providers. Though a measure to defund Planned Parenthood failed in April 2011, some legislators have suggested that there will be further efforts to defund the organization (Somashekhar 2009). It is crucial to stress that for many low-income women, family planning clinics may be their only source of primary and reproductive health care, so any reduction in revenue streams is likely to reduce these providers' capacities to fill gaps in the PPACA. At the same time, it may become financially difficult for safety net providers to continue to provide these services. Ongoing financial support from the public health infrastructure and safety net providers, which deliver care to populations that fall through the cracks of a complicated system or that have been left out of health care reform altogether, must be a critical policy priority under the PPACA.
The groundbreaking effort in Massachusetts to expand health care access for its residents offers a unique opportunity to examine how health care reform policies that build on the existing private health insurance system affect women's access to contraception and reproductive health services. Lessons learned about the experiences of low-income women, family planning clinics, and family planning agencies in Massachusetts can inform the continuing national debates about health care reform.