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Massachusetts Secretary of Health and Human Services Marylou Sudders.

(SHIRA SCHOENBERG / THE REPUBLICAN)

Gov. Charlie Baker's administration plans to cut $60 million from a state program that pays for health care for uninsured and underinsured individuals, partially by changing eligibility standards. Advocates for the poor worry that changes to program eligibility will force more people into debt when they cannot pay for their care.

The changes are scheduled to go into effect April 1, although some lawmakers are trying to delay them.

"This policy just cuts the program too drastically," said Neil Cronin, senior policy advocate for the Massachusetts Law Reform Institute, which provides legal services to poor people. "More people will be going into debt and won't be able to access the Health Safety Net."

The Health Safety Net is a state government-run program that reimburses hospitals and community health centers for care they provide to low-income people whose care is not covered by insurance. In fiscal year 2015, the Health Safety Net paid $403 million to cover health care for 274,000 people.

One-fifth of beneficiaries are elderly, many of whom have Medicare but cannot afford to pay the deductibles or co-pays. Other beneficiaries are immigrants who are ineligible for coverage, because they are undocumented or are waiting for asylum or other legal status. Some are family members of workers whose employer offers insurance, but for whom the cost of a family policy is prohibitive.

The Health Safety Net does not provide insurance. But when a person gets care at a hospital or community health center, rather than billing the patient, who will likely not be able to pay, the hospital can bill all or part of the cost to the Health Safety Net.

The program is paid for primarily by a fee levied on hospitals and health plans, but the state contributes $30 million annually - a payment Baker wants to halt in fiscal year 2017.

The biggest portion of the proposed savings - around $37 million annually - comes from enforcing an existing regulation, which says anyone eligible for state-subsidized health insurance, called ConnectorCare, can only get reimbursed by the Health Safety Net for 90 days. After that, the person must enroll in insurance through the Health Connector. Currently, 170,000 people whose care was paid for by the Health Safety Net are eligible for ConnectorCare, but 100,000 of them have not enrolled, according to the Office of Health and Human Services. The state only recently started enforcing this rule, because it did not previously have the software to make this determination.

Secretary of Health and Human Services Marylou Sudders said the biggest reason for the change is to make sure the Health Safety Net is not paying for people who should be getting insurance. "They're essentially getting free care when they're eligible for health insurance," Sudders said.

The more controversial parts of the changes would limit eligibility for the Health Safety Net. The administration wants to cut income eligibility from 400 percent of the federal poverty level ($47,080 for an individual) to 300 percent ($35,310 for an individual).

The administration also wants to cut the level at which a person does not have to pay a deductible from 200 percent of the federal poverty level ($23,544 for an individual) to 150 percent ($17,664 for an individual). Anyone who earns between 150 percent and 200 percent of the poverty level would have to pay an annual deductible of $516 (for an individual) before a hospital could be reimbursed.

Finally, a person who gets medical care now has six months to apply for reimbursement. The new rules would drop that to 10 days.

Sudders said the goal is to create consistency with MassHealth and Health Connector plans, which have similar standards. MassHealth is Massachusetts' Medicaid. The Connector is its insurance exchange, which offers subsidized and unsubsidized plans.

Sudders said the Health Safety Net comes out of an uncompensated care pool. Now that 97 percent of residents have insurance, and 170,000 people using the Health Safety Net are eligible for insurance, there is less of a need for the uncompensated care pool.

"We think it's important for those individuals to be signed up either through MassHealth or the Connector," Sudders said.

But advocates say the eligibility changes will hurt poor people who need health care.

Cronin said the program has had the same eligibility levels since the 1980s. Although Massachusetts has moved toward universal coverage, a portion of the population remains uninsured. According to the Massachusetts Law Reform Institute, in 2013, 7.6 percent of working age adults did not have insurance at some point during the year, and 4.8 percent were without insurance for the entire year. State figures now put the uninsurance rate around 3 percent.

"The number of uninsured is dropping, but it hasn't hit zero," Cronin said. "There's still residual folks who need to be picked up through the Health Safety Net."

Cronin said the 10-day time frame to apply for reimbursement is too short. Often, people seek health care at night when there is no one at a hospital to help them apply for reimbursement. People do not think about applying for reimbursement until they receive a bill. They might be too ill to fill out paperwork immediately.

Suzanne Curry, senior health policy manager for the advocacy group Health Care for All, wrote to Sudders opposing the changes on behalf of a coalition of health care advocacy and legal services groups, which calls itself the "Affordable Care Today Coalition." The group does not oppose the requirement that anyone who is eligible for the Connector use it. It does oppose the eligibility changes.

"We feel it's going to be an added burden on people who don't have any other option for seeking services," Curry said in an interview. She said the changes will hurt low-income people who have gaps in insurance coverage or no access to affordable coverage.

She worried about a "cascading effect," where people are billed for services but cannot pay, so hospitals and community health centers are stuck with bad debt and patients are mired in medical bills.

"As a true safety net program, the HSN should be there to assist people in all the situations in which they are unable to access affordable health insurance coverage," Curry wrote in the letter.

Curry wrote that the drop in eligibility "will impose cost barriers for the working poor, most of whom have no affordable health insurance options, and will impact people with high medical costs the most."

A group of lawmakers, led by State Sen. Jason Lewis, D-Winchester, chairman of the Joint Committee on Public Health, are trying to postpone the changes to give advocates time to make their case. An amendment Lewis introduced and the Senate unanimously added to a budget bill would keep current Health Safety Net eligibility in place through the end of the fiscal year in June.

Lewis and 44 other legislators wrote to Sudders urging her to reconsider the eligibility changes. "We are concerned that the proposed changes will harm residents who are already medically and socially vulnerable, and the health systems that care for them," they wrote.

The lawmakers said they worry about the impact of the eligibility changes on elderly people, immigrants, individuals waiting for new insurance plans to be activated, people with language barriers, the working poor and hospitals and community health centers.

"The erosion of (Health Safety Net) eligibility will be an impediment to necessary medical care for residents and lead to consumer medical debt and bad debt at hospitals and health care," the lawmakers wrote.