Health Reform Lessons from Massachusetts, Part I

Critical analysis begins to trickle in

Three years ago the Commonwealth of Massachusetts enacted a far-reaching health reform law that politicians and the media hailed as a model for other states and the federal government. Indeed that law has become the major blueprint for health system change on a national scale, and its advocates are aggressively marketing some variation of the Massachusetts plan as the reform of choice. Until recently, there has been little analysis of how the law has worked. Today we begin a series of posts that will explore the Massachusetts law with an eye toward helping the press and the public understand the flashpoints as legislation based on the Bay State’s experiment winds its way through Congress. The entire series is archived here.

In mid-February, the consumer advocacy group Public Citizen held a press conference alerting the media to the shortcomings of Massachusetts health reform. Familiar supporters of national health insurance—or a “single-payer system,” as it’s now euphemistically called—acknowledged that the law had had some success, but also pointed out several problems that up to that point had not been widely discussed. Dr. Rachel Nardin, who heads the Massachusetts chapter of Physicians for a National Health Program, noted that having health insurance was not the same as getting health care. Thirteen percent of people in the state who had insurance still could not pay for some health services, and 13 percent could not pay for their medicines, she said. Dr. Steffie Woolhandler, a professor at the Harvard Medical School, explained how the law encouraged the overuse of costly high-tech care while damaging the finances of safety-net hospitals.

The report—and an open letter to Senator Edward Kennedy, signed by 500 of the state’s doctors and urging Kennedy to push for a single-payer plan instead of a Massachusetts knock-off—got some press pick-up; but not as much as Public Citizen’s PR folks had hoped. The Boston Globe ran a short piece, and CBS gave it a mention. It was mostly specialized and trade pubs, though, like The Hill, Investor’s Business Daily, Health Plan Insider, and McKnight’s Long Term Care News, that carried the story.

Last week the Institute for America’s Future, a leftish advocacy group, released a similar report documenting what it considered failings in Massachusetts. Its key conclusion: “Since the Massachusetts plan does not contain any mechanisms for reining in the rapidly increasing cost of health care, the plan has limited potential for long-term sustainability.” Press coverage was still scant. Jonathan Cohn picked it up for his blog, Philip Klein posted on the American Spectator blog, and the Boston Herald ran a brief piece.

But the messengers of negative news, nevertheless, tried to put a positive spin on their poor-to-mediocre press showing. Angela Bradbery, Public Citizen’s communications director, said her staff had tried hard to generate interest at all the major news outlets, and that she was pleased that 250 journalists opened the press release. “We think it will greatly improve the coverage of this issue as the health debate unfolds.” And even good reporters are just “getting up to speed on health care choices,” said Diane Archer, a researcher at the Institute. She believes her group will have a long-term impact even if its report didn’t get next-day, nation-wide coverage.

The lack of media coverage that honestly looks at the successes and the failures of the Massachusetts plan, however, stands in stark contrast to the near-universal press enthusiasm that greeted the passage of the law in April 2006. Photos of Senator Kennedy, then-Governor Mitt Romney, and representatives of the state’s medical establishment and consumer organizations congratulating themselves—and headlines like “A Health Fix That Is Not A Fantasy” in The New York Times—seemed to say it all. Romney himself got a lot of ink when he proclaimed that “Massachusetts is leading the way with health insurance for everyone, without a government takeover and without raising taxes.”

The law essentially left in place the existing health insurance structure and rearranged money within the system. It required no serious cost-containment measures that would have assured the program’s future, but would have cut into the profits of the state’s powerful medical and insurance interests. Employers still cover their workers, insurance companies still sell policies that pay for care at the state’s high-end hospitals, and a federal infusion of cash allows the state to expand Medicaid coverage.

The law’s novel feature is its individual mandate—-the requirement that every resident must have health coverage either from a public program like Medicaid or from a policy sold by commercial insurers. If they don’t get coverage, they face a tax penalty, now about $1,000 a year. The state either fully or partially subsidizes premiums for individuals with annual incomes lower than about $32,500 and for families of four with incomes lower than about $66,000. For people who don’t qualify for government help, the state offers a shopping service called the Connector to make buying easier. Because of the mandate, some 97 percent of Massachusetts’s population now has health insurance.

Until recently, few have criticized the program. One health care provider who asked for anonymity told me: “Nobody wants to be quoted as going against Senator Kennedy. Nobody wants to be the one who says the emperor has no clothes. If you or your organization speaks out, you get cut off politically.” One state legislator who has spoken up is State Senator Jamie Eldridge. Earlier this year, Eldridge, who voted for the law, offered this candid assessment to a Congressional committee:

The assumption was that, as more people—and, in particular, more young and relatively healthy people—joined the system, premiums would go down across the board. There was also the assumption that as more people became insured, the number of people going to the emergency room would drop dramatically, saving the Commonwealth money. Neither of those things have happened—at least not enough to produce the cost savings we were told we would see. In fact, health care reform has cost the Commonwealth much more than expected—-up to a record $1.3 billion this year. It is maddening that so many of our public health care dollars are diverted to HMOs and health insurance companies, under the current employer-based Massachusetts health care system.

Politics inevitably led to the Blue Cross Blue Shield of Massachusetts Foundation, a philanthropic organization established in 2001 with a $55 million endowment from Blue Cross Blue Shield, the state’s dominant insurer, with the mission of expanding access to health care. The Foundation issued several reports intended to inform and influence the debate that lead to reform. Major funding for that initiative—called Roadmap to Coverage—came from Blue Cross Blue Shield of Massachusetts and Partners HealthCare (the big, influential health care system that includes Massachusetts General Hospital, the state’s huge teaching institution).

The Foundation has spread its money around to fund surveys gauging public opinion about the law and to help grassroots groups sign up residents for subsidized insurance. In January, it awarded $50,000 to Community Partners in Amherst to help with the group’s outreach efforts to enroll more people in public programs. It gave $50,000 to Health Care for All, the state’s premier health advocacy group, which has been a strong supporter of reform. In 2006, the year the law was passed, Health Care for All’s website disclosed that the Foundation, along with many of the state’s insurers and hospitals, each donated $10,000 or more to fund its advocacy activities. The group’s then-executive director, John McDonough, is now an aide to Senator Kennedy.

I sat down with Nancy Turnbull, who was president of the Foundation when the law was enacted and now teaches at the Harvard School of Public Health. The big winners, Turnbull told me (aside from those who now have subsidized coverage), “were the hospitals that got rate increases and lots of insured patients who didn’t have insurance before.”

“Insurers got lots of new business,” she said. “All plans picked up membership through the reform plan—and as a group, they are winners.” And the losers? They include the 100,000 or so residents who can afford coverage, Turnbull explained, but opt for the tax penalty. They also include the 85,000 people exempt from penalties because of religious beliefs, or who cannot afford what the state says is an affordable policy. They remain uninsured. Turnbull added some community health centers to her loser list, as well as people penalized by what she called the law’s inequities—for example, people who can’t get subsidized insurance if their employers offer coverage.

Turnbull’s assessment provides a different kind of roadmap—one that shows journalists where the good stories lurk.

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Trudy Lieberman is a longtime contributing editor to the Columbia Journalism Review. She is the lead writer for The Second Opinion, CJR's healthcare desk, which is part of our United States Project on the coverage of politics and policy. She also blogs for Health News Review. Follow her on Twitter @Trudy_Lieberman.