That’s my take on a new Massachusetts-based study, done by Harvard Medical School researchers and just out in the Journal of General Internal Medicine. Other states may want to take heed, now that the federal health overhaul has been upheld by the Supreme Court and they’re moving towards getting more people insured. All insurance is not the same, and for some, even the relatively generous Massachusetts Medicaid benefits may not be enough.

More on the study soon, but first, here’s the human side from its lead author, Dr. Danny McCormick of the Cambridge Health Alliance:

“For people who aren’t in the position of being at 133% of poverty, it’s inconceivable that [a $1 or $3 co-pay] would inhibit you from getting a medication if the doctor prescribed it. But I saw a patient last week, a young man with a chronic medical condition, who works at a deli, earns minimum wage, and rides his bike to work because he can’t afford a car.

I had seen him two months before and told him, ‘Your blood pressure is dangerously high, here’s a prescription for medication. You’ve really got to take it.”

So he comes back last week and he says, ‘You’re going to be unhappy with me but I didn’t take it.’

I said, ‘Okay, what were the problems?’

He said,’I've got Medicaid but I’m so far behind on bills I have actually no dollars in my pocket. I’m waiting for a check from work, and as soon as that gets here I can get that medication.’”

Moral of the story: “Even very small co-payments — and this is borne out in the literature — can inhibit extra-low-income people. This was a particularly striking case because he had such high blood pressure, and he showed up again and it was worse, and I ended up sending him to the ER, and that ends up costing fantastically more than the minimum co-pay he would have had to pay. I see it all the time as a primary care doctor: even very low co-payments inhibit needed care.”

The new study turns anecdote into data, with a survey of 431 patients who sought emergency care. From the press release:

The study authors surveyed 431 adult patients visiting the emergency room of Massachusetts’ second largest safety-net hospital. They found that patients with Commonwealth Care and Medicaid – the two programs through which most of the uninsured in Massachusetts gained coverage – reported similar or higher levels of access to and utilization of outpatient visits compared with the privately insured, as well as similar access to preventive care.

However, compared with the privately insured (7.0%), a significantly higher proportion of patients with Medicaid (30.0%) or Commonwealth Care Type 1 (26.8%) reported delaying or not getting a medication. Similarly, patients with Commonwealth Care (51.2%) and Medicaid (42.2%) were substantially more likely to report delaying or not getting dental care due to cost compared with the privately insured (27.1%). Those with Medicaid also experienced more cost-related barriers than privately insured patients when it came to seeing a specialist (14.6% vs 3.5%) or getting recommended tests (15.6% vs. 5.9%). This is despite relatively low patient cost-sharing requirements in these insurance types.

Patients with Commonwealth Care Types 2 and 3, which have greater cost sharing requirements, reported significantly more cost-related barriers to obtaining care, generally, than the privately insured (45.0% vs. 16.0%), as well as greater barriers to seeing a primary care doctor (25.0% vs. 6.0%), dental provider (58.3% vs. 27.1%), and to obtaining medication (20.8% vs. 7.0%).

The uninsured in the study fared substantially worse on every measure of access to care when compared with the privately insured.

“These findings illustrate that the insurance plans that most previously uninsured patients received in Massachusetts as part of health care reform had a mixed effect in terms of access to care” said the study’s lead author, Dr. Danny McCormick, an Assistant Professor at Harvard Medical School. “While patients with Medicaid and Commonwealth Care had difficulty finding physicians who would accept their insurance type, they were ultimately able to see primary care doctors at the same rates as privately insured patients”. However, he said, “our findings also suggest that these forms of insurance may leave low-income patients with substantial cost-related barriers to care not faced by the privately insured”.

Senior author Dr. Rachel Nardin, an Assistant Professor at Harvard Medical School, said: “health policy experts often assume that because Massachusetts health care reform decreased the percentage of uninsured in our state, that access to care would follow suit. However, our study illustrates that all forms of insurance are not equal. While Medicaid and publicly subsidized private insurance play a critical role in improving access to care for low-income people, our study shows that there is still work to be done to ensure equality of access”.

Dr. McCormick emphasizes that Medicaid and other public forms of insurance “play an absolutely essential role in improving access to care for low-income people. There’s no question about that…and any attempt to dismantle that or roll it back would result in substantially worse access to care for low-income people.”

“But the study also showed that Medicaid and Commonwealth Care plans leave patients facing challenges in finding a physician who accepts their insurance, and confronting a wide range of barriers of costs to care.”

For the second year in a row, the Massachusetts Health Connector’s Commonwealth Care program will provide private health insurance to eligible residents at a lower cost than the previous year. At tomorrow’s monthly meeting, the board of directors of the Health Connector will vote on bids from private insurance carriers that provide an average five percent reduction in per-person cost. Combined with similar savings achieved this year, tomorrow’s action will save the state approximately $91 million with no benefit reductions or member co-pay increases.
[...]
Commonwealth Care is the Health Connector’s health insurance program for uninsured adults who meet income and other eligibility requirements. There are currently 173,000 Commonwealth Care members and enrollment may exceed 200,000 during the next year. In the six years since health care reform became law, the per member per month rate the state pays to insurance carriers has increased by an average of less than two percent, while member satisfaction remains consistently high. In the most recent survey conducted during FY 2012, members rated their Commonwealth Care experience favorably, with 77 percent of all members being satisfied or extremely satisfied with the program.

“A key driver of overall cost reduction is unit cost improvement achieved through contract renegotiations with providers and referral management,” said Commonwealth Health Insurance Connector Authority Executive Director Glen Shor. “Several of the insurance carriers achieved significant success in persuading provider organizations to serve Commonwealth Care members at a lower cost.”

By the way, if you’re on Commonwealth Care, don’t assume this means your premiums will go down five percent. WBUR’s Newscast reports:

State officials say the bids from health insurance companies will amount to an average 5-percent savings per person covered by Commonwealth Care.

However, those customers could see their premiums go up or down.

They’ll have the chance to switch health plans though, before the changes take effect.

Network Health, a managed care plan owned by Cambridge Health Alliance, has just announced that as of July 1, its Commonwealth Care plan will cut its premiums by 15%. The cut will bring Network Health to the same price level as Celticare, which, with about 15,000 members, had been the only “lowest cost” Commonwealth Care plan. Now both will share that designation.

The announcement is timed to appeal to potential members during the open-enrollment period for Commonwealth Care, the state-subsidized health insurance for people with low and moderate incomes. The Network Health plan currently serves about 44,000 members, who’ll generally see a drop in monthly premiums of between $10 and $30.

WBUR’s Martha Bebinger reported in April that “plans that cover moderate-income residents through Commonwealth Care are holding rates flat by limiting where patients can go, negotiating tougher contracts with hospitals, and with better oversight of the sickest patients.”

In fact, The Globe reported then that the proposed limited-network contract from Network Health excluded all hospitals in the (expensive) Partners HealthCare system except two.

But that was when the news was about holding rates flat. Network Health is going a step further with its 15% cut, and I asked the plan’s president, Christina Severin, today how they were doing it.

She declined to discuss “exclusions,” like the Partners limits reported by the Globe. In general, she attributed the rate cuts to three main factors:

-Network Health had already been working “extremely hard” to control costs. In the current fiscal year, it had already seen zero growth in its medical expenses.

-Of the 15% cut, 10 percent comes through a “high value network”

-and 5% through “medical expense management.”

In other words, 10% from using lower-cost (though still high quality) facilities and 5% through the kind of proactive “care management” that keeps patients in better shape and thus avoids unnecessary expenses.

Christina provided a few telling examples of Network Health’s efforts at care management:

Mind and body: Network Health has a “fully integrated model,” meaning that mental health and social work staff work side by side with medical providers, she said. “And we really believe, based on what we’ve seen to date and what brought us to this 0 percent trend, that this model is highly efficacious.”

Aftercare: Follow-up for people discharged from the hospital, including a particular focus on people considered high-risk for complications. Is the patient clear about which medications to take and when? An RN will go to the patient’s home to make sure. Does the patient know how to care for a post-surgical wound? Same thing: An RN will make a house call to make sure. Is the patient able to get along at home, with enough food, perhaps a ramp if needed? A social worker may check.

Emergency Room: Another example: If a patient has just used the ER and is considered high-risk for using it again, an RN calls to check up. If they’re considered low-risk, an outreach worker will call. The calls might include some education on how to access primary care rather than the ER.

Hot spots: Then there are the 15% of members who need the most medical help and thus cost the most. By managing their care better, Christina said, costs for this population have been cut by about 5% compared to the last fiscal year.

Readers, plausible? Thoughts?

J., an educated and technologically capable man, went online to the state’s “health information portal” hoping to create an electronic account for Commonwealth Care, a subsidized insurance plan. He entered his name, social security number and date of birth. But the site spat back at him, “ReferenceError: Can’t find variable: ActiveXObject.” He tried again, and yet again. Finally, he called the functionaries responsible for the site, and after many minutes untangling the bureaucracy, received this answer: You cannot create an account on a Mac. You cannot use Firefox or Safari or Google Chrome. You can only use Microsoft’s Internet Explorer. This is a problem we hope to fix soon.

Sadly, Kafka is not here to do it justice, but this tale is true. When Jeff, a Hyde Park resident, first shared it, I confess that I doubted him. Can’t be! When was the last time I heard of an official Website that could only work with certain browsers? A decade or so ago??

So I tried it, on a Mac. I got the same error message. Try it yourself using Safari, Firefox or Chrome. Here’s the link. Hit the “Log In” button for Commonwealth Care, then try to Create a Login.

I called the Connector, the agency that helps Massachusetts residents shop for and obtain our (mandatory) insurance, and that manages the site that contains the health information portal. To be clear: You can use any browser to shop for and compare insurance on the Connector’s user-friendly site. And you cannot sign up with any browser for the Commonwealth Care program; you have to do it by mail. But if you’re already signed up and want to manage your account, you need Explorer.

Spokesman Richard Powers confirmed that the portal, which launched in June 2010, can only work with Microsoft’s Internet Explorer. The vendor that created it was Dell, he said. In his words:

“Our vendor’s product was initially written exclusively for Microsoft products and, in that sense, was somewhat outdated. It has always been their intention to upgrade the system to be compatible with other browsers such as Firefox 3.6, Apple Safari 5.0 and Google Chrome 9.0. We’re hoping to have that work completed by the end of the summer.”

Um — “somewhat outdated”??! Flamers, where are you? What do you have to say about a state that creates a Website in A.D. 2010 that cannot interact with any browser but Explorer? Please comment below. I can tell you that in an informal poll of the tech types I know, the word I heard most often was “Ridiculous!” The close runner up was “You’ve got to be kidding!” Though, they say, it’s not at all unheard-of, it’s just outdated.

Again, any browser can be used to explore and shop for insurance on the Connector’s broader site, Richard Powers emphasized. It’s just the “health information portal” — which about 36,000 Commonwealth Care members use to register, pay a premium or change a health plan during open enrollment — that has the browser limitations.

Sounds like a nice, convenient online interface — if you have a PC, that is. Jeff messaged CommonHealth:

I find this to be kind of absurd. If Amazon can get this right why can’t the State of Massachusetts? Actually every other state web site works with any browser. It’s only Commonwealth Care that’s so messed up.
They have been telling me for over a year now that they are trying to fix this. It’s amazing that this was even a problem in the first place. The other issue is that not many people use Microsoft’s Explorer due to all the security issues it has. Most people use Firefox.

Security issues? Oh, you mean like today’s reports of the potential leakage of personal information on more than 200,000 residents on the state’s unemployment rolls? Maybe it’s not actually so great to have a workable interface with state-run agencies.
Now, a computer inconvenience is not a great tragedy. But it is just one element in Jeff’s epic tale of trying to get the health insurance that Massachusetts requires of all residents. Even he calls it “a little Kafkaesque.”

It sometimes seemed to him, over the months he struggled with the bureaucracy and the faxed documents it demanded, as if the state were using any excuse to deny him care. “If it’s not deliberate, how is it possible that people are that incompetent?” he asked.

It began at the end of last summer, when he started trying to sign up for state-subsidized health insurance in the wake of a divorce. He found he couldn’t do it himself online, so he sought help from a kind financial officer at his local health center.

In all, it took him six months to get insurance, during which he worried that he might eventually be fined for lacking it. Along the way, the state twice lost all his paperwork. Now that he finally, happily, has Commonwealth Care at $154 a month, he must pay his bill by snail mail; it is not on the list of entities that can receive an automatic transfer from his Bank of America account.

The court said that Massachusetts erred in 2009 when it cut health coverage for about 26,000 immigrants after state lawmakers eliminated $130 million in funding to help balance the state’s budget.

The ruling did not order the state to reinstate full coverage for legal immigrants, but it paves the way for legal action by immigrant advocates that could do so.

The case was brought by Health Law Advocates, a partner to the consumer group Health Care for All, which said in a statement:

The ruling affects some 40,000 people, all legal, taxpaying residents of Massachusetts who were eligible for Commonwealth Care before the fall of 2009. About 20,000 people are enrolled in the Commonwealth Care Bridge program, which has lesser benefits and higher co-pays than CommCare. Another 20,000 are uninsured, locked out of coverage and relying on the Health Safety Net program for some care.

The recent substantial growth in tax revenues above forecast amounts (some $587 million in April alone) will allow the state to fund their re-integration into CommCare.

“We are very pleased that the Supreme Judicial Court has firmly and clearly stated that immigrants must have equal access to health care in our society. From the time legal immigrants were excluded from the benefits of the State’s health care reform law, we believed that law was unfair and unconstitutional. Now, it is time to remove this stain from our historic movement to provide health care for all and allow immigrants back into the Commonwealth Care program which has provided health care access to so many in our communities,” said Matt Selig, Executive Director of Health Law Advocates.

She explains:

For most of us, the price of insurance went up at least 7-10% this year. But plans that cover moderate income residents through Commonwealth Care are holding rates flat by limiting where patients can go, negotiating tougher contracts with hospitals, and with better oversight of the sickest patients. Glen Shor runs, who runs the state’s Health Connector says: “We’re very excited to test new models for delivering coverage in a more effective manner. We hope there’s something to learn from this experiment that can help other cost containment efforts.”

Shor says the state will save $80 million dollars by level funding Commonwealth Care.

The limits placed on where patients can seek care may be significant. The Boston Globe reports:

Shor said that a proposed limited-network contract from Network Health excludes all hospitals in the Partners HealthCare system except two, on Martha’s Vineyard and Nantucket.

NPR reports today that Pennsylvania’s entire state-funded health insurance program for low-income adults is about to be cut, leaving 42,000 members uninsured. Nearly 500,000 people had been on the waiting list, hoping to join the program.

States around the country are facing similar cuts in this season of exploding budget crises. In California, Gov. Jerry Brown is proposing to slash more than a billion-dollar swath out of state health programs, as reported here.

Not here in Massachusetts. As WBUR’s Martha Bebinger reported earlier this month:

In a tough budget year, the Patrick administration is out with a strategy to maintain subsidized coverage for 174,000 low to moderate income residents. While states around the country are trimming government health insurance, Secretary for Administration and Finance Jay Gonzalez says Massachusetts will preserve near universal coverage. “Our goal is to continue to provide coverage to everyone who is eligible for it, continue our nation leading record in access to affordable health care and to do in a way where we aren’t cutting benefits,” he says.

It remains to be seen how the legislature will react to the Patrick administration’s plan.

In a tough budget year, the Patrick administration is out with a strategy to maintain subsidized coverage for 174,000 low to moderate income residents.

While states around the country are trimming government health insurance, Secretary for Administration and Finance Jay Gonzalez says Massachusetts will preserve near universal coverage.

“Our goal is to continue to provide coverage to everyone who is eligible for it, continue our nation leading record in access to affordable health care and to do in a way where we aren’t cutting benefits,” he says.

But there’s no additional money for subsidized coverage, known as Commonwealth Care, and enrollment is expected to grow. In return for more members, Gonzalez is telling Commonwealth Care insurers they must provide the same care at lower costs. He says this is doable if the insurers limit where patients go and do a better job of managing care.

(Gonzalez will outline his plan for the next Commonwealth Care contracts at meeting of The Connector board today. He says he doesn’t expect any of the plans to stop participating in the program.)

Connector board member Dolores Mitchell, who is also Executive Director of the Group Insurance Commission, the agency that provides life, health, disability and dental and vision services to state employees, retirees and dependents, says Massachusetts, unlike other states, is not cutting benefits or limiting access to government insurance. “By and large we made a promise and we’re keeping it and I think that’s something to be proud of.”