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Health Insurance for All: What Massachusetts Can Teach Us

Massachusetts Governor Mitt Romney recently signed into law historic legislation that requires all Bay State residents to have health insurance, and expands access to coverage so that this ambitious goal might be met. This is certainly good news, for several reasons. First, any substantive effort to expand access to coverage is worthwhile, given the growing number of uninsured in this country and the large body of evidence showing the dangerous health implications of lacking coverage.

But something more important is at work here. While we urgently need a national solution so that all Americans have insurance, it doesn't appear that we'll be getting one at the federal level any time soon. So what Massachusetts has done potentially holds lessons for every state. One particularly cogent lesson is the manner in which the measure was crafted—via a civil process that successfully brought together numerous players from across the political, business, health care delivery, and policy sectors.

The Massachusetts Health Care Reform Plan is grounded in the idea that individuals, employers, and government must share responsibility for health insurance. The plan includes an individual mandate that says that it is every person's responsibility to have coverage and to be able to pay for care when they need it. And while Gov. Mitt Romney vetoed a provision requiring firms with more than 10 employees to provide coverage or pay a per worker fee, state legislators have vowed to override his veto and restore this provision.

To make it easier for individuals and employers to find and purchase affordable insurance, the plan offers a program called the Commonwealth Health Insurance Connector. It also provides government subsidies for health insurance to low-income individuals, and modestly expands MassHealth, a state program that provides coverage for poor adults and children. According to state legislators, the plan is expected to cover 515,000 uninsured within three years, leaving less than 1 percent of the population unprotected.

Will other states follow Massachusetts' lead? I hope so, particularly if some of the other states that have traditionally served as economic and social policy models for the nation—New York, California, and Maryland among them—can work toward similar solutions. It won't be easy, and it likely will take time. But never before have there been so many good reasons to take such action.

Without access to care, the uninsured can easily slip into crushing medical debt if they are seriously ill or injured. Safety net hospitals, clinics, and other health care providers are suffering financially because they disproportionately care for the uninsured. But perhaps most important, we simply cannot have a health care system that provides high-quality care efficiently if we have gaps in coverage. When people are uninsured, they don't seek preventive care that might catch certain conditions early, their care is more fragmented, and they are likely to use expensive emergency room care.

Investing in universal coverage—which Massachusetts seeks to achieve through modest increases in health care spending—will pay off in terms of a healthier, more productive population. Moreover, the health system will no longer incur as much of the administrative costs caused by people moving on and off of insurance plans when they switch or lose jobs.

There is evidence that other states will move toward improved coverage for their residents. Many already are trying to retain and expand employer participation in health insurance coverage, recognizing that it is hard to "go it alone" without financial contributions from employers and employees. Others are taking advantage of federal matching funds under Medicaid or the State Children's Health Insurance Program or developing policies to cover vulnerable populations. And some have generated new revenues from assessments on tobacco, health care providers, or insurers.

For example, on April 3, West Virginia's Governor Manchin signed a bill (HB 4021) intended to move the state toward universal access to basic health care. The bill expands eligibility in the State Children's Health Insurance Program to children with family income from 200 to 300 percent of the federal poverty level. It also includes a pilot program whereby up to eight providers would offer basic health coverage to uninsured residents for a low monthly fee.

Maine was the first state to endeavor to solve its uninsurance problem. Maine's Governor Baldacci signed the Dirigo Health Reform Act (PL 469) into law back in June of 2003. The purpose of the Reform Act was to make quality, affordable health care available to every Maine citizen within five years and to initiate new processes for containing costs and improving health care quality.

Of course, not all states are equal when it comes to their uninsured populations or their political wills to address the problem. For example, 11 percent of people under age 65 in Massachusetts lack health coverage, compared with about 15 percent of New Yorkers, 21 percent of Californians, and 16 percent of Marylanders. Some states might well want to wait for more financial help from Washington before making any bolder moves.

But bold action is indeed what's needed. And the states truly have the chance to serve as laboratories, test-driving promising approaches to improved coverage and tailoring their efforts to suit the needs of their populations. This might lead to 50 solutions as diverse as the states themselves. Or it might yield a few innovative strategies flexible enough to travel around the country and be adapted as needed. Either way, the efforts will be most welcome.

As always, I'd like to hear from you. Send your feedback to [email protected].


IMPORTED: www_commonwealthfund_org__usr_img_davis_sig.gif
May 2006




A video version of this column is also available online at Medscape. (Free registration is required.)

Written with the assistance of Christine Haran, web editor.




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