Some people who need care will always be left out. Because the building blocks of Massachusetts coverage are disjointed, people still seek treatment at the state’s safety net hospitals and emergency rooms, which wasn’t supposed to happen as people became insured. The Globe just reported that more people are seeking care in emergency rooms, and that the cost of treating them increased by 17 percent from 2005 to 2007, a period that includes two years covered by the law. The problem, it seems, is more complicated than simply mandating insurance coverage.

The significant reduction in the number of uninsured masks the discontent from people who fall through Kroeplin’s cracks and whose voices are not always heard in the media, or in glowing reports from the Massachusetts health establishment. For starters, thousands of residents don’t have to carry insurance. At the end of 2007, some 204,000 people remained uninsured. Nine thousand were exempt for religious reasons; 127,000 didn’t have to buy a policy because the state ruled that their incomes were too low to afford one; 68,000 paid the tax penalty.
Elisa McKernan, who spoke at a Boston forum last year, said that her family had lots of health problems but could not afford coverage. The state fined the family. Experts expect that these numbers will rise as the recession lingers, raising an unpleasant question that has been absent from the public discussion: Who is more deserving of insurance in a less-than universal system?

Undocumented immigrants and the mentally ill often fall through the cracks, as do the 20 percent of residents on Medicaid who cycle on and off the program. Medicaid, called Mass Health, is one of the state’s building blocks. State Health and Human Services Secretary Judy Ann Bigby told me half don’t send in their paper work to comply with the “redetermination process,” but she adds most get coverage when they get sick because providers get them back into the system.

Other people go bare, although they have employer-provided insurance. Many workers still decline that coverage because they can’t afford their share of the premiums. But the state doesn’t let them apply for subsidized coverage, even though that may be a better financial option. This is done to prevent “crowd-out”—wonk talk for making sure workers don’t choose a more attractive and cheaper option that takes business away from the private carriers. So much for consumer choice.

And any system based on financial eligibility holds an incentive for enforced poverty. If people try to earn more money because they need it, they get bumped into a higher tier in the state’s subsidized coverage and either their cost sharing goes up or they lose coverage altogether. They must choose between earning more money or losing subsidized insurance. NBC Nightly News briefly mentioned the problem, reporting on a clarinetist with the Boston Ballet orchestra who took a semester teaching job, earned more money, and lost his insurance. Its reporting should have gone much further. As the Financial Times reported last July in a package on the ailing U.S. health system, enforced poverty is a Catch-22. The FT shows a way for American journalists to tackle a missing piece of the story on individual mandates.

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Trudy Lieberman is a fellow at the Center for Advancing Health and a longtime contributing editor to the Columbia Journalism Review. She is the lead writer for The Second Opinion, CJR’s healthcare desk, which is part of our United States Project on the coverage of politics and policy. Follow her on Twitter @Trudy_Lieberman.