I am trying to reach the people who are normally on the very fringes of the healthcare system, and find out what, if anything, health reform is doing for them. Not surprisingly, it’s not easy to reach the most marginalized populations — especially as an outsider.

Holyoke is a very poor city, and therefore, home to many considered on the economic fringe. I started out the day at CEPA (Center for Education, Prevention, and Action), an agency that helps homeless people addicted to drugs. The agency helps sign people up for Mass Health and then helps them get into recovery programs. The director there, Daniela Falvo, told me that most of her clients are unaware of the new health care law, and wouldn’t care anyway. They are so much on on the outskirts of the system, and they tend to avoid doctor’s offices – which, they feel, look down on people like them. Their exposure to the health care system tends to be during emergencies — overdoses, exposure — and then they go to the Emergency Room, where they are used to getting free care. However, Falvo said her organization has nevertheless been trying to sign more people up for Mass Health — the state’s Medicaid program — which most if not all of her clients are eligible for. What do they gain from having MassHealth, they wonder? (since few would actually use primary care anyway.) She explains to them that the type of recovery beds they are eligible for increases if they have insurance like Mass Health. Otherwise, they are competing for a smaller number of beds reserved for the uninsured, and likely to wait longer to get into a program.

But, as always, I don’t want to rely solely on the advocates and practitioners. So I walked across the street to a coin-operated laundromat. I walked in and started looking for people I thought might have experiences with the health care system. The first three didn’t speak English, and this is simply too complicated a topic for my level of Spanish. In the back, however, I noticed a crock-pot of soup. Just outside the backdoor, I found a woman who was giving out the soup to ragged-looked men in the parking lot. As soon as I walked outside with my tape recorder, most of the men scattered. But the woman stayed. Her name is Wanda, and she used to work for CEPA until she was recently fired (sounded like a long story, which I decided not to get into.) She is originally from Puerto Rica — a tall, blond, elegant looking woman — and has worked in some capacity for the community for 25 years. Although she’s now unemployed (and getting MassHealth), she still tries to help people living on the streets get food and shelter, and sign up for MassHealth — a process they find extremely confusing. Even after they get into the program, they don’t realize they must keep reapplying, which causes many to be thrown off it.

Wanda called over one man who had been getting warm inside the laundromat. He seemed rather beaten down. He told me, through Wanda’s translation, that he used to be addicted to heroin, and then to methodone, and now he’s stabilized, having gone through a few recovery stints. He was once kicked off of MassHealth, but is now back on, with Wanda’s help. So I pull out my microphone and ask him if he had heard of the new health reform law and if he had any thoughts about it — and as soon as I did that, I realized how out of place the conversation must have seemed. No, he said, gazing very suspiciously at my microphone, he didn’t know what I was talking about. And I realized I probably need to come at this much differently when I’m dealing with such a marginalized population.

A woman I stopped in the McDonald’s parking lot told me that she recently lost her job and her employer’s health insurance, and that now she’s on MassHealth, but that she really didn’t want to talk to me about it, and no, she wouldn’t give me her name.
Last stop — the bus stop. A 50-ish woman who appeared to have some diminished mental capacity told me that she was uninsured for many years but now is on Commonwealth Care. A ha! A sign of the health reform law in action. She had been to the doctor once for a physical, and figured she should probably go back. I wasn’t able to coax too many details out of her, but that was more my problem, not hers.