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Come Together

Massachusetts has been a model of health reform. Its 2006 plan, a compromise between Republicans and Democrats, has improved access to care while keeping costs well within projections. That’s the real lesson of the recent Senate vote.

By Rachael Moeller Gorman and Charlie Slack // Jan. 26, 2010
bipartisan handshake


Republican Scott Brown’s surprise victory in Massachusetts’s special senatorial election on January 19 has been widely interpreted as a referendum on Democratic plans to reform health care. For many observers, Brown’s election in a heavily Democratic state held an irresistible irony, in that Sen. Ted Kennedy, who held the seat for almost 47 years until his death in 2009, had made national health care coverage one of his signature goals. Brown openly campaigned on a promise to stop the Democrats’ plan in its tracks by breaking their 60-seat, filibuster-proof Senate majority.

But the voters’ decision presented another irony. Just four years ago, Massachusetts embarked on its own version of universal health coverage for the state’s 6.5 million residents—and the plan seems to be working remarkably well.

As Proto outlined in an infographic published as the program was getting started (“Health Coverage for All,” Fall 2006), all individuals without insurance were required to obtain it by December 31, 2007, or face a penalty when filing their taxes. Major insurance companies had to participate in a new marketplace called the Connector, through which individuals could buy affordable, good-quality plans approved by the Connector. The state expanded its version of Medicaid, MassHealth, to include people in higher income brackets and began subsidizing low-to-middle income people who didn’t qualify for MassHealth. The federal government helped pay for it all with health care reimbursements, and companies with more than 10 employees had to subsidize health insurance premiums, or pay a fine.

So far, the successes of the plan seem to outweigh the drawbacks. About 10% of the state’s residents were uninsured before reform (compared with approximately 15% nationwide), a number that has since dropped to the lowest in the nation, 2.7%. And access to care has improved: Interviews conducted by the nonpartisan Urban Institute with 10,000 Massachusetts residents, revealed that more people now have a primary care physician or other usual source of care (92.1% in the fall of 2008 vs. 86.4% in the fall of 2006). The survey also found that they are more likely to have had preventive medical (76.8% vs. 70.2%) and dental care (76.3% vs. 67.8%). These gains were strongest for lower-income adults: 87.3% had a primary care physician or other usual source of care in the fall of 2008 vs. 79.3% in the fall of 2006. And according to the Massachusetts Taxpayers Foundation, another nonpartisan research group, the cost of achieving near-universal coverage “has been relatively modest and well within early projections of how much the state would have to spend to implement reform.” The cost to taxpayers? An extra $88 million per year, or an additional $13.50 per person per year on average.

The system does face difficulties, some of which are beyond the state’s control. The shortage of primary care physicians, for example, has made it difficult for newly insured adults to find general practitioners accepting new patients, particularly in the Berkshires and on Cape Cod. “The most significant challenge remaining is getting a handle on the growth of costs,” says Brian Rosman, research director at Health Care for All, a nonprofit advocacy organization in Boston. In the year after the plan’s launch, the financial burden of health care dropped because premiums and co-pays were lower with the new plans, but in the second year much of those gains evaporated as premiums grew more expensive.

“Near-universal coverage will become unaffordable unless serious cost controls are put into place,” agrees Jon Kingsdale, executive director of the Connector, that near-universal health care is actually possible in the United States. He and others contend that the keystone of the program—mandating that individuals get coverage—is crucial, because it drives down the cost of insurance for everyone (partly because large numbers of young, healthy males, one group less likely to be otherwise insured, now must purchase insurance, which makes it possible for insurance companies to charge lower premiums for those in poor health). In addition, Massachusetts understood that a task as large as “reforming one-sixth of its economy,” as Kingsdale noted in an April 2009 statement before the U.S. Senate Committee on Health, Education, Labor, & Pensions, required room for trial and error. It created a strong statutory framework but would allow for change, such as reforms currently under debate that could fundamentally shift how physicians and hospitals get paid, rewarding quality and positive results. The Connector, meanwhile, is largely free of politics an independent state agency with a diverse board of directors that conducts its business transparently and publicly.

As Congress and the Obama Administration grapple with just what Brown’s election means for the health care reform movement, they might draw one additional lesson from the Massachusetts plan: The role that bipartisan support plays in an initiative this large is indispensable. Four years ago a Republican governor (Mitt Romney) and a Democratic legislature were able to put aside their differences for a common goal—indeed, Brown, then a Republican state legislator, voted for the plan. Says Rosman: “The Romney Republicans and liberal Democrats were able to find compromises and, without too much acrimony, reach an agreement. If Washington wanted to, they could probably find agreement as well. We’ve shown that it’s possible.”

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