Mass Appeal

Polls show that Americans are confused about what health care reform means. And, if you listen to members of Congress on television, you get the impression that some of them aren’t certain, either. But figuring out what health care reform entails isn’t hard. All you have to do is look at Massachusetts.

Almost three years ago, the state introduced an ambitious initiative designed to make sure nearly all residents have health insurance. Under this scheme, the state requires employers to contribute toward the cost of covering workers, while requiring individuals to get insurance. It sets up regulated marketplaces, through which individuals and small businesses can obtain insurance, and it forbids insurers from denying coverage, or charging higher rates, because of preexisting conditions.

These are the same key elements you’ll find in the reform bills moving through Congress--which is precisely what has a lot of people worried, on both ends of the ideological spectrum. Conservatives tend to see Massachusetts as a classic case of government run amok. Liberals, although more sympathetic to the basic idea, say the reforms have provided too little coverage for too much money. There’s even one argument on which critics from both sides agree: Massachusetts hasn’t figured out a way to restrain the overall growth in health care costs. If national health care reform fares no better, the country could be in serious fiscal trouble.

The critics have some valid points, particularly on the question of costs. And, with key details about national health care reform still unresolved, understanding the shortcomings in Massachusetts could help lawmakers make the right choices. But the more significant story about Massachusetts is the one that gets told too rarely: the story of what’s gone right. If Massachusetts offers a preview of where we are headed nationally, then Americans can look forward to a health care system that, however imperfect, will be vastly better than the one we have now.

Health care reform in Massachusetts was actually the product of a long struggle that dates to the 1980s, when the state passed a law requiring employers to offer coverage to their employees or contribute toward the cost of covering uninsured workers. It was an ill-fated, if noble, effort: Before the law took effect, employers won repeal of its central provisions. Chastened, lawmakers in the ensuing years focused on incremental reforms, such as expansions of public programs for children and the restructuring of a fund to help subsidize charity care. The initiatives helped, but plenty of residents still struggled to find affordable medical care--either because their insurance was inadequate or because they were among the 10 percent of residents who had no coverage at all.

In 2006, though, reform advocates finally got a chance to try something big again. It was all thanks to a fortuitous political circumstance--one that spawned an unlikely alliance between Republican Governor Mitt Romney and Democratic leaders in the legislature. The Bush administration had decreed that it would not renew a special “Medicaid waiver,” under which Massachusetts channeled some federal money to large safety-net hospitals, unless the state redirected the money toward expansion of insurance coverage. Compelled to act, Romney and the legislature agreed on a scheme that blended ideological approaches and demanded compromise from both sides. There would be insurance for everybody, but everybody would have to pay what they could for it. Liberals wouldn’t get a single-payer plan or anything close to it; conservatives would have to put up with a large expansion of government, even by Massachusetts standards. Fittingly, Senator Ted Kennedy--who’d helped orchestrate the deal from Washington--appeared alongside Romney at the signing ceremony in Boston’s historic Faneuil Hall.