According to a survey study by the Urban Institute, the portion of 18 to 64 year-olds in Massachusetts without insurance has shrunk significantly since 2006, but the costliest gaps persist. The uninsurance rate is still far higher among people with household incomes under three-times the poverty line (a threshold targeted by state subsidy programs). The percentage of adults persistently lacking health coverage over the past year was about seven times greater in the lower-income group versus higher-income population (3.5 percent and 0.5 percent, respectively).

Another striking statistic in light of the racial overtones in the healthcare battle on the Hill: Latinos made up 13.3 percent of the uninsured, but just 7.5 percent of those fortunate enough to be included under “universal” healthcare. State budget woes have eroded coverage for immigrants, even those with legal status.

Another analysis by Physicians for a National Health Plan shows that the state's uninsured rate remained about the same from 2007 to 2008, “before strict enforcement of the individual and employer mandates went into effect.” According to PNHP Co-founder Dr. Steffie Woolhandler, centrist reforms in Massachusetts show that “plans that require people to buy private insurance don't work. Obama's plan to replicate Massachusetts' reform nationally risks failure on a massive scale."

Insurance gaps aren't the only problem. The Kaiser Family Foundation reports that the primary care infrastructure has been perilously stretched as the system has absorbed more patients. And while more people may nominally be covered, many facing economic or medical hardship are still priced out of essential care:

Of the total population, 21 percent went without needed care in the previous year because of cost. People with disabilities and those in fair and poor health experienced the greatest barriers to accessing care.

Community health centers (CHCs) and safety net hospitals continue to play a crucial role in caring for the newly insured and in providing a safety net for the uninsured. Between 2005 and 2007, the total number of patients served by CHCs rose by 50,000; safety net hospitals also experienced a slight increase in low-income patients. Despite increased patient volume, the financial situation for CHCs remained the same and declined for safety net hospitals.

Generally, low-income people and communities of color rely heavily on clinic-based care. According to the Commonwealth Fund, in addition to serving millions of uninsured patients, “community health centers and other public clinics care for 20 percent of low-income adults who have health insurance." And while Blacks and Latinos are often cut off from mainstream care providers,

a larger proportion of minority than white adults name community health centers or public clinics as their regular source of care. More than one of five Hispanics and 13 percent of African Americans use community health centers or public clinics as their regular place of care, compared with only 9 percent of whites and 7 percent of Asian Americans.

If Congress follows the Massachusetts model, it might come up with a plan to incrementally chip away at the country's towering uninsured rate. But lawmakers haven't even come close to dismantling the racial and economic structure of healthcare inequity.

Image: AP / Catholic Health Association