The patients we cannot afford to lose

Consider a patient I expect to see: a 53-year-old home health aide who has worked the same job for 11 years — nights, weekends, the hours no one else wanted. She has been putting off her chest pain for months. “I didn’t want to bother anyone,” she will tell me. “And I wasn’t sure I was still covered.”

She will be right to worry. Under the new federal rules now taking effect, her Medicaid coverage is at risk of lapsing — not because she will be ineligible but because she might miss a semiannual renewal notice that arrives while she is working a double shift. By the time she understands what has happened, she might have no insurance, no recent lab work and a stress test that has gone unscheduled for two years.

I’ve seen patients delay care before for cost, for fear, for the particular stoicism that runs through working communities in this region. But what I fear is coming is something different. What is happening to coverage in Massachusetts right now is not one thing. It is three things arriving at once.

First, a sweeping federal budget law passed last summer tightened who qualifies for Medicaid and added new requirements to keep it. Roughly 325,000 Massachusetts residents are projected to lose coverage over the next decade as a result, and the state stands to lose up to $3.5 billion a year in the federal funding it uses to run the program.

Second, federal subsidies that helped working families afford Affordable Care Act marketplace coverage expired at the end of 2025, and Congress did not renew them. For many households, premiums more than doubled. Massachusetts has stepped in with partial state assistance, but some families simply have concluded they cannot pay the new number.

Third, the eligibility rules governing both programs have grown genuinely difficult to understand — not just for patients, but for everyone. The rules are not designed to be navigated alone, whether you’re a home health aide working nights, a self-employed carpenter or a recent immigrant navigating a system in a second language.

As a physician, what concerns me most is not simply the number of people who are likely to lose coverage; it is what that loss means in real life. The first casualty is almost always primary care. Without insurance, a patient does not call for an appointment with a primary care provider she cannot afford.

She waits. The blood pressure goes unmonitored. The diabetes management visit gets skipped.

The routine exam that would have caught a lump or an arrhythmia or a warning sign in a basic blood panel never happens.

And when there is no primary care relationship, there is no gateway to what follows: no referral to a cardiologist or specialist. Strip that relationship away, and you do not just eliminate a visit; you eliminate the entire clinical chain that turns early detection into treatment. The patient does not disappear.

She reappears later — in an emergency room, when the condition is no longer manageable, only expensive.

None of these pathways to losing coverage announce themselves clearly. Research on prior Medicaid redetermination waves consistently shows that a substantial share of people who lose coverage do so for administrative reasons alone, not because they no longer qualify. They are working the hours needed to prove they are working the hours required to keep their coverage.

There is a particular cruelty in that arithmetic. And alongside those traps, there is a second layer: people who still qualify for help but cannot figure out whether they do or what kind or where to apply.

The rules have changed so many times, in so many directions, that keeping up requires a kind of literacy most people do not have time to acquire.

The ripple effects extend into the institutions designed to care for these patients. As Berkshire Health Systems CEO Darlene Rodowicz told The Eagle last week, the system is already tightening its belt — reviewing which services and hours of operation can survive as federal dollars contract. Hospitals statewide are estimated to lose $424 million annually.

For a region like ours, where margins are already thin and workforce shortages already strain capacity, these cuts do not arrive into a stable system.

I retired from hospital medicine, but I did not leave the practice of it. I now volunteer at a free health care center in Pittsfield that serves uninsured patients: people who fall through every gap in every coverage system we have ever built. In 40 years of medicine, I have never seen a moment when that kind of work mattered more or when the distance between a patient and a diagnosis felt more contingent on paperwork than on pathology.

What happens to the woman who missed the notice, who delayed the stress test, who was right to worry is not inevitable. It is a policy choice. And in communities like ours, the response to that policy choice cannot wait for Washington to reverse course.

It must be built here by institutions that have decided access to care is not a benefit to be earned through administrative compliance. It is a condition of a decent society.