By Christopher Lee
Washington Post Staff Writer
Sunday, July 1, 2007;
BOSTON --
There is a lot of talk about overhauling health care in the United States,
but Massachusetts is actually trying to do it -- again.
Today, the home of some of the nation's most prestigious hospitals and medical schools
becomes the first state to require its residents to have health insurance or face
financial penalties. Making insurance mandatory -- and more affordable -- for Massachusetts'
s 6.5 million residents is the centerpiece of a law approved by the legislature last
year that civic and business leaders hope will dramatically reduce the ranks of the
state's 400,000 uninsured and the number of people who seek costly "uncompensated"
care in hospital emergency rooms.
This is not the first time the state has attempted to tackle the problem. Nearly
20 years ago, then-Gov. Michael S. Dukakis signed universal health-care legislation
that was supposed to bring coverage to everyone by 1992. But the law's requirement
that employers provide coverage to workers or pay a tax proved unpopular, and it
was never implemented.
Still, Massachusetts'
s new grand experiment could become a model for major changes in health care across
the country -- if it works.
Already Democratic presidential candidates are borrowing some of its elements for
their campaign platforms, Gov. Arnold Schwarzenegger (R) is pushing a similar plan
in California, and other states are watching closely.
President Bush signaled last week that state experiments such as Massachusetts'
s will play a key role in remaking a U.S. health-care system that he described as
too costly, too confusing and leaving too many people uninsured.
"States should make reforms to ensure that their citizens have access to basic private
health insurance," Bush said after meeting with health-care experts at the White
House. "If we want a better system, the federal government has got a responsibility
to reform, and so do states. . . . The choices we make now will set the direction
of medical care in America for years to come."
Their place in the national spotlight is not lost on the Massachusetts officials,
business leaders and consumer advocates who forged an unlikely alliance to get the
law passed in April of last year. They know that would-be reformers around the country
are hoping that they will succeed, and that skeptics were quick to cluck over early
reports this spring that the new state-facilitated insurance plans might be unaffordable
for average residents.
"They might like to imitate us, some of them, but a lot of them can't wait for us
to fail," said Jon Kingsdale, executive director of the Commonwealth Health Insurance
Connector Authority, the new state entity implementing the law. "It's actually very
helpful pressure, because people in Massachusetts feel the pressure of the national
eyes on us, so they are particularly concerned that this not fail. It actually gives
us more momentum."
Although July 1 marks the beginning of the "individual mandate" -- the legal obligation
to obtain health insurance -- the real deadline is Dec. 31. When Massachusetts residents
file their state tax returns next spring, they must certify that they had acceptable
coverage as of the end of 2007 -- or lose the $219 personal exemption. The penalty
grows steeper in subsequent years, big enough, officials hope, to persuade most holdouts
to get coverage.
The state's 175,000 employers have to pitch in, too. Businesses with 11 or more full-time
employees that do not offer health insurance must pay an annual "fair share" assessment
of $295 per employee. And businesses must arrange to allow workers to pay health
insurance premiums with pre-tax dollars.
"We need to be fair and lenient in terms of enforcement both on employers and individuals
in the first year in order to not incur some kind of a backlash," said Richard C.
Lord, president of Associated Industries of Massachusetts and a member of the Connector
board. "We need to . . . give everybody a chance to adjust to the new realities."
The government, for its part, is defining basic coverage and trying to make insurance
more affordable. Under its new Commonwealth Care program, it is subsidizing coverage
with no annual deductible on a sliding scale for people with incomes of up to 300
percent of the federal poverty level, or $61,950 for a family of four. About 130,000
low-income people are already enrolled either in Commonwealth Care or MassHealth,
the state's Medicaid program, state figures show. The poorest pay no premiums.
Those who do not qualify for subsidies and cannot get coverage through their jobs
can buy low-cost but unsubsidized health plans offered by private insurers through
the Connector under the Commonwealth Choice program. Premiums go up with age, but
people cannot be charged more if they are sick or be denied coverage because of a
preexisting condition.
Costs are still too high for some. Already, state officials expect to exempt 60,000
residents from the new mandate because they cannot afford the insurance at the going
rates, even though they earn too much to qualify for subsidies. That is a big reason
that Massachusetts is destined to fall short of universal coverage under the new
law, officials say, although proponents say covering 99 percent of residents is possible.
"Affordability is the big question here," said Kathy Swartz, a professor at the Harvard
School of Public Health, who noted that even those with a basic plan could face high
deductibles. "It's certainly what a lot of other states are wrestling with -- how
do you bring the costs down?"
The state's costs are a concern, as well, with some analysts wondering whether Massachusetts
will be able to keep funding the $1.6 billion-a-year program if the economy slumps
or if costs rise substantially over the next few years.
"This is not an enterprise for the faint of heart," said former Democratic state
lawmaker John McDonough, executive director of Health Care for All, a nonprofit group
that pushed for the new law. "There are always risks. There are always problems.
There are always clouds on the horizon that could turn into a storm. Get used to
it."
About 57 percent of all Massachusetts residents say they support making health insurance
compulsory, according to a poll released last week by the Kaiser Family Foundation.
But two-thirds of respondents said they expect the new law to cause their taxes to
increase. And 72 percent said they did not know the deadline for getting coverage.
The plain fact is that most residents will not be affected directly by the new law
because more than 90 percent already have insurance, often through their jobs or,
for the elderly, through Medicare.
Charles Paine, 64, a cab driver from the Boston suburb of Waltham, said he supports
the law. Paine, who has diabetes, already receives help from the state and said he
expects to enroll in one of the subsidized plans.
"I'm one of the ones they call working poor," he said. "I make enough to get by,
but I don't have enough to pay my bills and have health insurance. I think it's ludicrous
not to have health insurance for everyone. I don't think you should work your whole
life, and get sick, and lose everything you've worked for. It will be tight for me,
but I've got to have it."
