Universal Health Care: Massachusetts

The worst of it, Stephen Gore thought, had passed. There was the kidney cancer, and then there was the operation to remove it, and finally, after a year and a half, it looked like it might actually be over. Not over over, because you never know with cancer, but over for the moment, over for this year, over except for the ever-present thought that it could return. He'd gone to see the doctor and get the PET scan. If it showed no hot spots, it would be the last one for a while. He could count himself as cancer free.

It was a Friday. Right after the PET scan, he drove from the Manet Community Health Center in Hull, Massachusetts, back to his job on a computer help desk, and as soon as he got back, he got called into a meeting. Last day-pack up your stuff, please. And by the way, your company health insurance ends tomorrow.

Gore went home and started looking for a new job. The PET scan results came in on Tuesday: no hot spots, no cancer-for now. There'd still be appointments with the doctor in the years to come. But for now it looked okay.

Gore knew that Massachusetts had passed a statewide health care plan, and maybe he'd be eligible, but it felt like a handout and he didn't think of himself as the kind of person who took government handouts. He could continue on his employer's health plan for 18 months, at $1,175 a month for him and his wife, Robin Flint.

Of course, he didn't have a job, and Robin's part-time piano-tuning business wouldn't come close to bringing in enough. The $1,175 seemed completely out of reach; it may as well have been a million. Gore thought he'd make do without health insurance. It was only when he was sitting in the living room and the house was quiet and he heard Robin wheezing from the next room that Gore realized she was skipping her asthma medication to save $175 a month. He went right back to the Manet Community Health Center and signed up for Massachusetts's new subsidized health insurance program, Commonwealth Care.

There's a very good chance that you can imagine yourself in Stephen Gore's shoes. Sixty percent of Americans have health insurance tied to their jobs (or their spouses' jobs). The system of employer-provided health insurance that started with the Big Three automakers in the 1940s and 1950s is showing bigger cracks every year. Employers are less likely to offer insurance than they were in the past, and virtually all are asking their workers to pay more for the coverage they do offer. A survey by the nonprofit Kaiser Family Foundation in April showed that 28 percent of Americans, more than one in four, had serious trouble paying for their family's health care needs. Close to 50 million Americans have no health insurance at all. That's why health care is a centerpiece of the 2008 presidential election. Both nominees, Senator John McCain and Senator Barack Obama, have presented far-reaching health care reform plans. (For details, go to readersdigest.com /2009health.)

Meanwhile, one place stands out in the national health care debate: Massachusetts is the only state that has embarked on an ambitious plan to make sure all its citizens have health insurance. It's not a new idea. California governor Arnold Schwarzenegger proposed a state plan in 2007, Bill Clinton proposed a national plan in 1993, and Earl Warren and Harry Truman proposed plans for universal coverage as far back as 1945. Massachusetts, however, is the first of the 50 states to pass legislation that aims at universal coverage. The plan that passed in 2006 created Commonwealth Care, the program through which Stephen Gore got health coverage.

Commonwealth Care has made Massachusetts a test bed for some of the key ideas for a national health care fix-and a flash point for the debate about what we can afford to provide and who should pay for it. The Massachusetts experiment is a study in what can realistically be achieved by a universal health care plan, as well as the costs and trade-offs it takes to get there. For some of the state's uninsured, such as Gore, Commonwealth Care has been a godsend, but for others it imposes some pretty steep costs. In an election year in which both parties promise to reform health care, Massachusetts might point the way to a national model and also might hint at why achieving universal health coverage on a national level could be a tall order.

Jonathan Gruber is a Massachusetts Institute of Technology economist who was a key architect of many of the ideas behind the state's plan. He aimed to come up with a system that would cover the state's working-class uninsured. The object was to make high-quality care affordable for everyone. But at the same time, nobody wanted a plan that was so heavily subsidized by the government that it would make employers drop their health coverage, crowding out private insurers and effectively making the state's plan the only game going. And it had to be cost-efficient: Gruber's goal was not just to provide insurance for those who couldn't pay for it, but to get those who could pay but were going "bare" to buy insurance-since they often wound up with bills they couldn't pay, a cost that the state and other patients ultimately have to cover. "Individual responsibility," says Gruber, "is a hallmark of the plan." The idea was to get everybody in, providing insurance for those who desperately wanted it and couldn't afford it, but also nudging into the pool some folks who'd rather take their risks without insurance.

The 2006 Massachusetts health care plan has two central pieces. Commonwealth Care was the first subsidized care for people with lower incomes. Individual premiums range from nothing to $116 a month (see chart). The insurance is provided by four nonprofit insurers.

The other key part of the plan is a requirement that, in most cases, everybody have health insurance. Those who don't have insurance must get it by paying the Commonwealth Care premiums if they are eligible or full price if they aren't. Gruber, and ultimately the state, concluded that trying to coax people into buying insurance just plain wouldn't work. So the state's legislation includes a mandate, which means fines for people who don't get health insurance.

The word mandate embodies the most controversial part of Commonwealth Care. Many similar plans considered over the years (including Hillary Clinton's) have depended on including young, healthy people reluctant to buy health insurance at anything but a minimal cost. Why? Because any plan that doesn't include a high proportion of healthy people is going to be very expensive for individuals to buy or the government to subsidize. In fact, it could go into a death spiral, as healthy people leave and it becomes ever more expensive for those who stay in. That's why, for the designers of the Massachusetts plan, including a mandate was the only economically feasible choice. The bottom line, says MIT's Gruber, is that any plan without a mandate would cover a lot fewer people while costing the state almost as much as a universal plan. "Without a mandate," Gruber says, "we'd cover only one-third of the uninsured, at two-thirds of the cost."

Opponents of Commonwealth Care point to the mandate as an unnecessary government intrusion into health care choices. (Mitt Romney, the governor of Massachusetts who signed Commonwealth Care into law, opposed making coverage mandatory.) And supporters also have their qualms, worrying that some older residents who aren't eligible for subsidies don't earn enough to realistically afford insurance. Bill Walczak, CEO of the Codman Square Health Center in Dorchester, points out that even the least expensive plan available would cost a 58-year-old woman earning $32,000 a year close to 14 percent of her income. "If the state wants health insurance for everyone," says Walczak, "they need to figure out how to lower the cost."

So for some people, Commonwealth Care presents the painful choice of paying for insurance they can barely afford or having no insurance at all.

Since Massachusetts enacted its health care law, the state has cut the number of the uninsured by more than half, with 173,000 people signing up for one of the Commonwealth Care plans (110,000 more, pushed by the mandate, have joined their employers' health plans).

The state expects the Commonwealth Care total to reach 342,000 in 2011, according to the Boston Globe. Some of them-says Christina Severin, the executive director of Network Health, one of the nonprofit insurers in the Commonwealth Care program-have also needed more care than the state expected. "The people who have the most urgent health problems," says Severin, "have been the quickest to get in line."

The program is expected to cost $869 million this year, and $1.35 billion a year by 2011. That's in addition to what the state pays to insure children under a separate program, and to what it pays hospitals that provide care to the uninsured. It's more than Commonwealth Care was expected to cost, even though more citizens in Massachusetts were already insured than those in most other states (72 percent of people there get insurance through their jobs, versus 60 percent nationally).

It has also created a health care bureaucracy that hasn't always operated smoothly. Those who worry that any expansion of the government's role in health care can lead to any number of boondoggles will certainly find material to chew on in Massachusetts. Even avid supporters of Commonwealth Care have sometimes found the gears of the machine to be a little creaky. Severin says that her plan has seen many members lose their coverage-some more than once-because of bureaucratic snafus.

Writer Mike Mennonno visited his local clinic for a checkup and was told he could sign up for Commonwealth Care. He expected to get a bill for an $18 premium. Instead he got one for $662. For a cholesterol check. "It just seems a little steep, is all," Mennonno wrote on his blog. After many calls, things turned out okay with the bill. Then this year Mennonno was asked to reenroll and send in his tax forms. So he did-and was told that his pay stubs, not his tax forms, were required. Now he might be fined for not enrolling in time. Mennonno says that paying the fine might be a bargain compared with dealing with the state agency that runs Commonwealth Care. At least his cholesterol was fine.

In the end, however, it's probably the tough economics of universal health care that might make a plan like Mas_sachusetts's hard to stomach for a lot of the country. You can go back to Stephen Gore to see why.

Gore, as it happens, found another job several months after signing up for Commonwealth Care. Still, he thinks the state program was a boon. "I was able to keep my sanity," he says, and that made it a lot easier to find a job. "There's nothing," he points out, "like a crazy person showing up at a job interview." He went into interviews more relaxed, expanded his search, and soon had a job running a computer help desk, a step up from his old one.

Gore's new job provided health insurance from day one. If it hadn't-or worse, didn't provide insurance at all-he and his wife would have had to buy their own. Gore's new income would have meant that they were no longer eligible for inexpensive state-subsidized rates; they'd have had to buy their insurance at full price. Even the least expensive plan available through Commonwealth Choice, the state's list of individual plans offered by six nonprofit insurers, would have cost $783 a month for him and Robin, and that would have come with a $2,000 deductible for each of them. Mulling over those numbers, even Gore, a big fan of the Massachusetts system, concedes that with his current paycheck, that would have been a lot of money. He's glad that with the benefits at his new job, figuring out whether he and Robin could afford the state's insurance mandate isn't something he had to do. "I'm thankful it didn't come to that," says Gore.

There, in a nutshell, is the big quandary of universal health care: A system like Commonwealth Care that includes subsidies for some is likely to seriously stretch the resources of others.

The ultimate test of the Massachusetts experiment may be not in how effectively it manages to provide care for those who can't afford insurance on their own, but in how well it does in getting all the others to buy in.

As of today, Stephen Gore remains cancer free.

Source: Reader's Digest

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