Immigrants Bring Discrimination Case Over Insurance Experiment

By Andrea Smardon

Nov. 1, 2010

BOSTON -- The state Supreme Judicial Court hears oral arguments Monday in a case involving legal immigrants who feel they've been unfairly treated by the state regarding their access to subsidized health insurance.

Lawyers for four immigrants have filed a class-action suit that charges that the state violated their constitutional rights by dropping them from the Commonwealth Care insurance program last year.  In a budget-cutting move, the state contracted with a for-profit insurance company to provide cheaper coverage for this population. The deal saved the state $90 million.

Regardless of the outcome of the lawsuit, the deal may be a preview into the future of health insurance for more Massachusetts residents.

Maria Reyes says she can't afford the copays for her six prescriptions under her insurance with Celticare. (Andrea Smardon/WGBH)

Maria Reyes sits on a loveseat in her small, one-bedroom apartment in Everett, rifling through a plastic container filled with medications. “These two medicines I have to take two times a day, and this one pill a day,” Reyes counts off. “And these three – I have to take two pills per day for each one.”

Reyes has six different prescriptions.  She takes them because her thyroid was removed when she had surgery for throat cancer.  And she has diabetes.  She says she needs the medication to live, but when she runs out, she doesn’t have the money to get more.

For Immigrants, A New Program

Reyes hasn’t seen a specialist for a year.  The last time she went to see her doctor at Somerville Hospital, she was told that her Commonwealth Care insurance no longer covered her there.  Eight days later, she was told that she was enrolled in the Commonwealth Care Bridge program, and she should get her care in East Boston. 

“When they sent me away from this hospital, I cried because I had really good doctors in that hospital,” Reyes said.

When Reyes was in Commonwealth Care, she didn’t have to pay for doctor’s visits. But on her new program, Celticare, that’s changed. “They told me if I want to see the specialist I have to pay $25.  If I’m very sick and I go to the ER – I have to pay 25 and I can’t afford,” Reyes said.

There are about 23,000 immigrants like Reyes enrolled in the Bridge program.  They’re called Aliens with Special Status (AWSS), and they’re all legal immigrants, though not citizens -- most of whom have had green cards for less than five years.   Amid budget cuts last year, state lawmakers wanted to drop this group from subsidized insurance entirely because the federal government doesn’t reimburse states for their care.  

Under pressure from Gov. Deval Patrick, lawmakers agreed to fund limited coverage – but only allocated a budget for a third of what was originally projected to insure the population.  Put out for bid, the only insurance provider that said it could offer coverage at the reduced price was Celticare, a subsidiary of the for-profit company Centene. 

Part of Celticare’s approach is to use a selective network of providers, so some patients had to change doctors.  

Questioning Celticare

Ruth Hertzman-Miller is a doctor at Somerville Hospital, a part of the Cambridge Health Alliance – which lost about 1,500 patients to the Bridge program.  She says she and her colleagues were concerned about what was going to happen to these patients.

“Here we were as primary care doctors taking care of a subset of patients – who first of all couldn’t see us anymore – and who we were starting to hear stories. It wasn’t clear how good their access to a new physician was going to be,” Miller said. “So we just had a concern about what’s going to happen to my patients when their medical care gets disrupted in this way.”

Dr. Hertzman-Miller and two residents conducted their own independent study.  They called all the providers in the Celticare network within a five-mile radius.  They found that less than a third of the primary care providers were taking new patients, and there was an average wait of 33 days. 

Dr. Hertzman-Miller says her concern about a private company like Celticare is that it has an incentive to keeps costs down by limiting the care it provides. She says she fears that the company is using the Bridge program to make inroads into the Massachusetts insurance market. 

“So I think there’s a distinct possibility that somebody looked at this strategically and said hey, let’s get into the business of providing care to these members, we won’t have to provide that much care and it will allow us to get into the market,” Hertzman-Miller explains.

Executives at Celticare strongly dispute Dr. Hertzman Miller’s claims. CEO Richard Lynch says her data is incomplete, and that the number of providers available is significantly more than her data showed. 

"We Were The Only Ones Who Stepped Up"

Celticare commissioned its own study in March.  Lynch says a majority of its members reported they were satisfied with their coverage, and 90 percent of patients who saw a physician were happy with the coverage they got. 

“These numbers are in line with numbers we see in surveys for health care coverage across the country.  Primary care access in Mass. and across the country is something we know we can improve on, we can all improve on,” Lynch said.

He added that Celticare patients may be experiencing the same frustrations – like long waits and co-pays – that patients experience across the board. “Is it possible that our members experienced something similar to what other members are experiencing in other health plans, absolutely yes. Our job is to look at creative solutions to that access problem,” Lynch said.

Lynch points out that this population would not have any health insurance at all if Celticare didn’t step in to do the job.

“The Bridge program was a situation that was presented to all of the health plans in CommCare in Mass.  And we stepped up together with our provider partners to help provide a solution there… and we were the only ones who stepped up to provide that kind of coverage,” Lynch said. 

“We thought it would be a good opportunity to showcase what we could do… that we could provide fairly comprehensive coverage to a vulnerable population and do it for less,” Lynch added.

Lynch says Celticare could not have provided the level of coverage it does at its price price on its own. It was a collaborative effort with its health care providers and the state. 

The Discrimination Case

Now, the state is being called to defend itself in a class action lawsuit brought by the four immigrants who lost access to Commonwealh Care insurance. Matt Selig, Executive Director of the Health Law Advocates, says that the plaintiffs were denied their constitutional right to equal treatment under state law when they were dropped from its insurance program. Selig says the Bridge program doesn’t absolve the state. 

“The case we filed is about discrimination.  The fact that our plaintiffs have been provided some assistance through the Bridge program isn’t a valid defense for the Commonwealth in this case,” Selig said. “They’re receiving not as good coverage as they would under the Comm Care program so they’re being discriminated against as a result of that.”

Glen Shor is the Executive Director at the Connector Authority, which oversees state insurance programs.  He declined to comment on the lawsuit, but he defended the Bridge program.

“The Bridge program is comprehensive coverage.  It certainly meets our network adequacy standards.  The benefits and cost sharing is comparable though not identical to Commonwealth Care coverage,” Shor said.

Shor says the Bridge alternative provides a meaningful alternative to no care at all for legal immigrants. “Would we prefer ultimately to serve this population with Commonwealth Care? Absolutely,” Shor said.  “But we stared at the very real prospect is that this population would have no coverage.”

The Celticare "Experiment"

Shor points out that, in 2014, federal resources will become available to cover this population of legal immigrants. In the mean time, funding for the program is only secured through the end of this year.  Shor says whatever happens, the program has been a valuable learning experience for the state.

“The experience with Celticare will be educational for the commonwealth. One benefit of this experience is having the opportunity to experiment with selective networks and learn from the experience,” 

But from Maria Reyes’ perspective, the change has amounted to a failed experiment.

“The only thing that I ask is, ‘Please take this insurance, and give me the insurance that I have before,’” Reyes said. “And my favorite is Somerville hospital and I want to go back there.  It was the first hospital I went to when I first came to this country.”

If the plaintiffs prevail in the lawsuit against the state, the legislature may be forced to return legal immigrants like Reyes to the rolls on Commonwealth Care insurance.  But regardless of the outcome of the case, the Bridge program may be a preview of what’s to come in state-subsidized insurance.  As Glen Shor at the Connector Authority says, the Celticare experiment will inform lawmakers’ future health policy decisions.

CeltiCare Aliens With Special Status Coverage Proposal

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