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Medicaid

    HEALTH CARE

    Medicaid Cuts Will Be Costly for Outer Cape Health Services

    Many Outer Cape patients will lose their insurance, especially legal immigrants

    By

    PROVINCETOWN — A multitude of changes to health care in the “One Big Beautiful Bill Act” that was signed into law on July 4 have experts in Massachusetts sounding two alarms: about people’s access to care and about the financial resilience of health-care providers.

    New rules will make it much harder for people to sign up for health insurance and stay enrolled — and the resulting surge in uninsured people will make it much harder for Outer Cape Health Services (OCHS), which must serve all residents on the Outer and Lower Cape whether they have insurance or not, to stay afloat.

    “Seeing how hard it’s going to be for people to maintain benefits or even get access — it’s truly devastating,” said Hannah Frigand, who supervises a hotline at Health Care for All Massachusetts that helps state residents sign up for health insurance. “It’s heartbreaking to see us backslide — many people will be harmed, and health-care systems will be harmed.”

    “These are the largest cuts to Medicaid in the program’s history,” said Alex Sheff, senior director for policy at Health Care for All Massachusetts. “We have not seen a threat to coverage and care and health equity in Massachusetts like this” since Medicaid was created in the 1960s, Sheff said.

    “This is going to be a crisis,” OCHS CEO Damian Archer told the Independent. “A lot of people are going to get pushed into an uninsured or less-insured status, and we don’t know how we will be able to continue to care for all those folks.”

    The changes in the One Big Beautiful Bill Act are numerous, and some of them are designed to appear small. Nonetheless, the Congressional Budget Office estimates that they will cut $1.1 trillion from federal health-care spending over 10 years.

    “It’s a cut by 1,000 paper cuts,” said Frigand. “Red tape is being added in the Health Connector and on the marketplace side and in MassHealth, and it was designed to create confusion and make it much, much, much more difficult to stay enrolled.”

    Middle-income earners signing up for plans in the state’s online marketplace, for instance, will need to pay full price for a new policy before they can find out if part of the cost will be subsidized, Sheff said. “Many people will look at that high price and say, ‘There’s no way I can pay that,’ and we’ll lose them — they won’t get covered,” he said.

    People with “Medicaid expansion” plans, which in Massachusetts are called MassHealth Care Plus, will need to verify their income twice a year and their current working hours at least that often, Sheff said, which could knock almost half of those people out of enrollment.

    The new law also cancels rules that protected patients from being disenrolled from Medicaid because of unopened or returned mail.

    In addition to the individual suffering of people who lose their health insurance, the loss of paying customers is a major risk for nursing homes, community hospitals, and community health centers, Sheff said.

    “People will die from these policies, and medical debt will devastate people’s finances,” Sheff said. “Community health centers will also be under tremendous financial strain.”

    MassHealth payments make up about 40 percent of Outer Cape Health’s billable revenue, Archer said.

    “The federal government is not going to double our funding to accommodate the influx of people without insurance,” Archer said. “The math is not math at all.”

     

    Cuts to Immigrant Care

    A series of other changes in the July 4 law will bar many classes of immigrants from access to health care.

    Refugees and people who have been granted asylum will no longer be eligible for either Medicaid or Medicare, even if they have paid Medicare payroll taxes for more than 10 years, Frigand said.

    A larger group of immigrants who had been eligible only for “Connector Care,” or marketplace plans, will no longer be able to use premium supports to buy those plans, which will effectively disenroll up to 60,000 legal immigrants in Massachusetts, according to the executive director of the state’s Health Connector, Audrey Morse Gasteier. That group includes people who received a green card in the last five years, people with Temporary Protected Status, and legal non-immigrants, including H-2B and J-1 visa holders.

    “The folks who are being dropped from this coverage have legal status — they went through the right channels, they have documentation, and they’re going to be ineligible for federal support for this care,” said Sheff.

    And a separate policy change, announced by Secretary of Health and Human Services Robert F. Kennedy Jr. on July 10, would bar undocumented immigrants from accessing any care at community health centers like Outer Cape Health Services.

    Before that change was announced, Archer had told the Independent that “what I am most concerned about is something equivalent to the Hyde Amendment with abortion — something that makes it illegal to provide services within the health care center” with any federal funds.

    Removing some immigrants from the health center’s mandate to serve all Outer and Lower Cape residents would be “a complete disaster,” Archer said on June 30, and would force people to seek care at hospital emergency rooms instead.

    Kennedy’s July 10 memo reinterprets clauses of a 1996 welfare reform law and declares that access to community health centers is a “federal public benefit” that must be denied to undocumented immigrants. Access to emergency room care was not changed by the new rules.

    The law requiring community health centers to serve all patients in their areas has also not changed, Archer told the Independent on July 14, so he expects the new prohibition on serving undocumented immigrants to be challenged in court.

    “As of today, we’re not doing anything different” with respect to care for immigrants, Archer said, except “waiting for guidance” from federal agencies and national organizations. “It’s possible we won’t have a responsibility to verify,” which could lead to a “ ‘don’t ask, don’t tell’ type of situation,” he said.

    “This is a very marginalized and vulnerable population,” Archer said. “These are people who help our community to function and who we love and care for, and I feel we’re at a crossroads because the health center’s hands may be tied” if a prohibition on care goes into effect, he said.

     

    Payment Up-Front

    On July 1, Outer Cape Health Services changed its approach to payment for walk-in services for people who are not already patients of the health center.

    Instead of charging a $50 co-pay up-front and billing insurance companies for an “urgent care provider visit,” Archer said, the health center is now requiring patients to pay the $290 cost for the appointment first and then forwarding the bill to see if insurance companies will reimburse their patients.

    The clinic’s new outside billing contractor pointed out that the health center was not getting reimbursed for many walk-in visits, Archer said, because it is a nationally accredited urgent care center but not a state-licensed one. “We have no evidence that Outer Cape was ever licensed to be a state urgent care facility,” Archer said, and the billing contractor “did due diligence and found out that we never got paid for this properly.

    “I took this information to the board of directors in June,” Archer added, and they supported the change to up-front payment for walk-in care.

    The health center still offers a sliding scale for lower-income people for walk-in visits, even people who are not Outer or Lower Cape residents, Archer said. “You disclose your income and your family size, and there are some steps we take afterward to verify that information, but if you’re a visitor on your first visit, we take you at your word.”

    Access to care is not delayed for income verification, Archer said. People who don’t qualify for the sliding scale but still are not prepared to pay $290 can pay $50 and set up a payment plan.

    The change is not a direct response to the looming cost of the newly uninsured, Archer said: “Regardless of what was happening at the federal level, this is good business.”

    But the upcoming costs of caring for the uninsured are certainly on the organization’s radar. “We need to maximize our current revenue to be prepared for what’s coming in the future,” Archer said, “so there is an indirect connection.”

    HUNGER

    Outer Cape Food Pantries Prepare for Rising Need

    Local organizations assess how cuts to SNAP and Medicaid will hit home here

    By

    WELLFLEET — With a new federal budget that cuts SNAP benefits (known as food stamps) and Medicaid, local food pantries are preparing to address what they expect will be an increase in food insecurity on the Outer Cape.

    Barbara Bond is a volunteer at the Truro Food Pantry. Wellfleet and Truro have both seen 21-percent increases in visits at their pantries so far this year. (Photos by Nancy Bloom)

    “It’s going to be harder and harder to stay ahead of the need,” said Maria Burks, a volunteer at the Wellfleet Food Pantry.

    Over 11,000 households in Barnstable County received monthly help from SNAP, the federal Supplemental Nutrition Assistance Program, as of 2023, according to the most recent data available from the U.S. Census Bureau. According to a Mass. Law Reform Institute analysis, the new budget will put 175,000 state residents at risk of losing some or all of those benefits.

    At the same time, Census data show that more than 41,000 people in Barnstable County had their health care covered through Medicaid. Rollbacks will add medical bills to people’s basic expenses.

    The losses of both forms of support are likely to lead to higher demand at local food banks.

    “If your family doesn’t have enough SNAP benefits at the end of the month, they’re going to come to their nearby food pantry, so when these changes go into effect, we expect to see more folks relying on our 600 partners,” said Kate Adams, a senior public policy manager at the Greater Boston Food Bank, which distributes food to all of the Outer Cape towns’ pantries.

    Volunteers at the Wellfleet Food Pantry said they saw their busiest day ever last month, with a record 42 people. “Even though we had a delivery that morning, by the end of the day our shelves and our freezers and our refrigerators were looking rather bare,” said Cindy Batchelder, one of the volunteers.

    According to Katie Wibby, CEO of the Lower Cape Outreach Council, a nonprofit that helps Outer Cape food pantries coordinate with the Greater Boston Food Bank, Wellfleet and Truro have both seen 21-percent increases in visits at their food banks so far this year.

    The optimistic explanation as to why more people are visiting food pantries is that there is more awareness of the service they provide. But the data offer a bleaker explanation: increased hunger across the region. In Barnstable, Dukes (Martha’s Vineyard), and Nantucket counties, 34 percent of the residents faced food insecurity at some point in 2024, according to a Greater Boston Food Bank study. That number was 20 percent in 2023.

    About 80 percent of the food the Wellfleet pantry stocks comes from the food bank in Boston, while the rest comes from cash donations. Volunteers at the pantry buy some items, such as cooking oil and toilet paper, from local supermarkets using those funds.

    In February, Wellfleet’s food pantry got a grant from the nonprofit Broadway Cares/Equity Fights AIDS. In a letter presenting the grant, Executive Director Danny Whitman cited “the many challenges thrust upon us by the unsettled political landscape.”

    At the Provincetown Food Pantry, the need used to fluctuate seasonally; now, there’s high demand year-round, according to Nicola Vichert, who manages the pantry there. “It ticks up in the summer because we have a lot of J-1 people using the pantry, but even when they leave at the end of the season, we’re still busy right through the winter,” she said. “On a busy day, we could easily have 30 or 40 clients.”

    Ana Carrillo, who cleans hotel rooms at the Bradford in Provincetown, hasn’t received SNAP benefits, but her wages still aren’t enough to cover her expenses and pay for food. She told the Independent she’s been using the Provincetown pantry for six years.

    Though she is 65 and retired, Carrillo still works 32 to 36 hours per week for $20 an hour, eight or nine months each year. She’d like to work more hours, but then money would be withheld from her Social Security benefits.

    “I wish I could work full-time, but then I’d have to pay them,” said Carrillo. “The pantry helps a lot.”

    Preparing for the Worst

    The people who visit the Wellfleet food pantry include seasonal workers, shellfish workers, seniors on fixed incomes, homeless people, and people working two or three jobs, the volunteers said. Recently, Burks said, they were soliciting donations outside a local grocery store when a woman walked past them saying, “I’m on SNAP, and I’m expecting to lose it any day.”

    Najia Sbai working at the Truro Food Pantry on July 15.

    For the last few months, the Wellfleet Food Pantry has been operating out of a 720-square-foot trailer in the parking lot of Our Lady of Lourdes Catholic Church on Route 6. It’s larger than the space they had before but still not big enough to store sufficient supplies for the growing number of people who come by.

    More room for the pantry can’t come soon enough, Burks said. Earlier this month, the Wellfleet Select Board accepted the food pantry’s proposal to lease town land at the senior center using money raised through private donations. They hope their new space, which could be as large as 2,000 square feet, will be ready by the end of 2026.

    The Lower Cape Outreach Council has also been working to increase capacity at its main food bank in Orleans in anticipation of Trump administration policies.

    “We’re tripling the size of it, so we’re hoping that having the increased capacity will allow us to source more food at reduced cost because we can buy in bigger bulk, and we’re putting in a walk-in freezer,” said Wibby.

    At the Truro Food Pantry, manager Barbara Bond has already had to start limiting how much food each person is allowed to take — something she hates to do, she said, though she anticipates needing to do it more often. “We don’t know how bad it’s going to be,” Bond said. “I put out requests in various ways for donations.”

    According to a worst-case-scenario estimate by the Greater Boston Food Bank, if everyone who loses SNAP benefits turns to food banks, demand could increase by as much as 55 percent.

    Even before the latest cuts, the Greater Boston Food Bank faced a challenge from the Trump administration. A few months ago, it had a $2.5-million shipment of food canceled by the federal government. While the current budget doesn’t affect funding for food banks, officials fear that shipments could be canceled again in the future.

    “We did not receive a reason from the federal government as to why that was canceled,” said the food bank’s Adams. “Things are pretty unpredictable right now.”

    HEALTH CARE

    Budget Cuts Could Cost MassHealth $2 Billion Per Year

    Medicaid is vital to OCHS — but a state bill could help steady the books

    By

    PROVINCETOWN — A 10-year budget resolution that could strip up to $880 billion from Medicaid passed the U.S. House in February, raising the prospect of large cuts in the MassHealth program.

    According to an interview with former Congressional Budget Office director Doug Elmendorf, posted by the Harvard Kennedy School, the bill is a “reconciliation instruction,” which means the Senate’s version, which has not yet been published, could pass with only 50 votes and avoid a filibuster by Senate Democrats.

    If the cuts were spread evenly across the states, they would cost each state about 16 percent of its federal Medicaid funding.

    Massachusetts would lose $2 billion per year for the next 10 years, according to a KFF analysis. That is about double what the state is now raising with its new 4-percent surtax on income over $1 million.

    Outer Cape Health Services CEO Damian Archer told the Independent that at any given time, between 20 and 25 percent of the health center’s 20,000 patients are covered by MassHealth.

    While changes to MassHealth are still hypothetical, Archer said, “if there are shifts in the way the states have to find a way to pay for Medicaid, the state may then become more restrictive in who is eligible.”

    One idea circulating among Republicans is to target the expansion of Medicaid that took place under the Affordable Care Act of 2010, which in Massachusetts helped bring the state’s uninsured rate to less than 2 percent of the population in 2023.

    Other proposals would add work requirements or require income re-verification every six months — which reduces the overall cost of Medicaid mostly because so many people fail to complete the paperwork and are kicked out of the program, according to a report by the Center for Budget and Policy Priorities.

    Archer said that he and the leaders of other community health centers are advocating against any new work requirement for Medicaid. Fewer than 10 percent of patients at OCHS are uninsured, but any increase in the uninsured rate would create new costs that would be passed on to other patients, Archer said.

    When people delay preventive care, they are more likely to wind up in the emergency room, which “triples or quadruples the cost of care,” Archer said. Those increases “get passed on to everyone, like a tax,” because hospital bills get passed on to commercial insurance companies, which then raise premiums.

    Uninsured patients are also a direct cost to OCHS, because federally qualified community health centers are required to provide care for all patients regardless of ability to pay. Outer Cape Health Services has a “sliding scale” for charging uninsured people for health services that is based on the patient’s income, Archer said, but it is well below the cost of the care.

     

    Commercial Insurance

    Patients losing their MassHealth coverage and becoming uninsured isn’t the only threat to the bottom line at OCHS, Archer said.

    The health center is actually much better compensated by MassHealth and Medicare than by the commercial insurance companies that employers use, he said. Insurance plans like those from Tufts, Boston Medical Center, and Blue Cross Blue Shield are regulated by the state but negotiate their reimbursement rates with providers, and according to Archer, the health centers don’t have much bargaining power compared to larger hospital-based systems.

    “If we were paid the ‘prospective payment system rate’ that we are paid for Medicaid and Medicare patients by our commercial payers — if we were just to get the same rate across all our insurers — that would be huge,” Archer said. Medicare and Medicaid are effectively subsidizing the insurance companies, which sometimes pay community health centers just a third of what Medicare and Medicaid would, he said. OCHS often loses money on care that’s paid by commercial insurance, he added.

    “There was a state bill that included changes to the commercial payment floor for community health centers that didn’t pass last year, but I know Sen. Cyr filed it again,” Archer said.

    “Now that we’re in this environment where there are existential threats to our organization” — including the loss of other kinds of direct federal funding to community health centers, as the Independent reported last month — “I’m hopeful the state legislature will take a second look at it,” Archer said.

    “It’s still really early in the session,” said state Sen. Julian Cyr — but he is hoping that Senate Bill 711 or something like it could become law. The bill would require commercial insurance companies to match the rates MassHealth pays to community health centers. Earlier this year, Gov. Maura Healey signed legislation creating a task force on primary care access, delivery, and payment, and Cyr said that rate equity could become a priority for that task force.

    “When we look at who is providing primary care, mental health care, and prenatal care to some of the most vulnerable people in Massachusetts, community health centers are the leaders in that care,” Cyr said. The Mass. League of Community Health Centers helped draft last year’s bill, he said, which passed the Senate but never made it into conference legislation with the state House.

    This year’s bill is currently at the Joint Committee on Financial Services.

    “The number-one factor affecting our ability to get more patients in the door is our ability to pay competitive wages,” said Archer. If reimbursements from private insurers suddenly equaled those from Medicare and Medicaid, Archer said, he would put the additional funds toward recruiting and retaining staff and expanding services.

    “It’s a concrete, solid, very logical, very fair bill that just makes sense,” he said.

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