About four out of five people in Massachusetts who go without health insurance do so because they say they can’t afford it, according to a report out Thursday from the Blue Cross Blue Shield of Massachusetts Foundation, which advocates for equity in health care.

The report highlights barriers that remain in accessing health insurance, even in a state that implemented a health care reform law 17 years ago with affordability as one of its aims, and a state that has the highest percentage in the country of residents — about 97% — who do have health insurance.

“Most of the people who are uninsured, they want insurance,” said Audrey Shelto, president and CEO of the Blue Cross Blue Shield of Massachusetts Foundation. “There are barriers to them getting it.”

Shelto said affordability, limited awareness about subsidized programs and a complex insurance system are all major barriers to getting more Massachusetts residents insured.

In seeking to fix the affordability problem in the state, the foundation’s report offers 13 policy and program recommendations. Those include increasing the number of people eligible for the state’s ConnectorCare program, which offers commercial insurance plans that have low or no monthly premiums, low co-pays and no deductibles.

Shelto said the foundation looked closely at the demographic details of hundreds of thousands of residents who are uninsured in Massachusetts, and found that someone is more likely to be uninsured if they are between the ages of 19 and 34, Hispanic, Black, work for a small business or in a low-wage industry, or pay more than 30% of their income for housing.

For instance, Hispanic residents make up 12% of the state’s population, but the foundation’s analysis of data from an April 2020 state report, finds they account for 23% of those who have gone without health insurance.

Cara Vogel of North Adams, who is mixed race, worked in her early 30s as a part-time housekeeper in a hotel near a ski resort, with take-home pay near $20,000 a year.

Vogel — whose story the foundation included in a video that accompanies their report — said the best health insurance she could find would have cost her an entire week’s salary every month, and then there was the deductible.

"The way that they explained it to me was that the [deductible] was $3,500, and ... without the deductible paid, my health insurance wouldn't even kick in."
Cara Vogel

“The way that they explained it to me was that the [deductible] was $3,500,” Vogel told GBH News. “And I would have had to pay the $365 [per month] and figure out how to pay the $3,500. Because without the deductible paid, my health insurance wouldn't even kick in.”

Vogel said, being young and healthy, she decided to go without insurance for three years. She has a full-time job now, and can afford insurance for peace of mind. She says her coverage amounts to less than 10% of her take-home pay after taxes.

“If I need to go to the doctors or if I have any kind of emergency, I don't have to worry about showing up at the hospital and worrying about the $10,000 bill I'm going to get in the mail in two months,” she said.

Shelto said it’s unfortunately a common story in Massachusetts that people either have low-paying work and the math of paying for health insurance just doesn’t work for them, or else they lose a job and face hurdles affording insurance, or navigating a complex and at times confusing bureaucracy in accessing their health insurance options.

“This isn't right; this isn't what we are as a commonwealth,” Shelto said. “People shouldn't be going through this. We can fix this and we should fix it.”

Beyond affordability, the foundation’s recommendations address transitions for people who start making too much money to stay on MassHealth, the state’s Medicaid program, or who have a job loss or job change. The foundation also recommends finding solutions to coverage gaps that result from missed deadlines for filing paperwork.

And finally they address problems facing immigrant groups, which include language barriers, and also legal status of immigration. The foundation is advocating that MassHealth and ConnectorCare offer health insurance coverage “to individuals and families regardless of immigration status.”

Dr. Charles Anderson, the president and CEO of Boston’s Dimock Center, a community health resource center in Roxbury, pointed out that often the barriers outlined in the Blue Cross Blue Shield of Massachusetts Foundation’s report are intertwined.

“We're often seeing people who are not able to access the system in any other way,” Anderson said. “And they're often coming to us in the context of being undocumented. And that impacts their ability to think about how they are able to get the same sort of care, because it does invoke these challenges in terms of affordability.”

Anderson, who is also a member of the Health Equity Compact, a group of over 65 leaders of color, backed the proposal to extend coverage to people regardless of immigration status, saying it’s a matter of “pay now or pay later.”

“Think about it like this: we always talk about the value of preventative care,” said Anderson. “And oftentimes preventative care is nowhere near as expensive as the care that you have to provide when someone's now on a list for a heart transplant because they're in heart failure, because their hypertension hasn't been managed.”

“Pay a little bit now, make sure someone has access to the medications that they need, access to the basic care they need, or end up paying later and a lot more. And we're not just talking about the economic cost; it also is the human cost as well.”