Some patients have insurance in another state that cannot be used in Massachusetts. There are those who have insurance, either through an employer, Medicaid or the ACA, but cannot use it in Massachusetts. We have a substantial transient population in the Berkshires – farm workers, creative and performing artists, theater and concert support staff, students, nannies, housekeepers, etc. – who spend extended periods of time here but whose coverage does not reach beyond their home state. Medicaid, for example, although largely federally financed, is a state run program and cannot be used across state lines. ACA policies, too, are state-by-state and usually incur a substantial out-of-network co-pay. And, of course, there are those whose immigration status makes them ineligible for ACA coverage.