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. This is the second in an occasional 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.

Last summer, The Boston Globe reported on a poll by the Harvard School of Public Health and the Blue Cross Blue Shield of Massachusetts Foundation that examined what Massachusetts residents think about the state’s health insurance law. “Support for law varies, poll shows,” read the Globe’s headline. The lede went further:

More than two-thirds of Massachusetts residents support the state’s two-year-old near-universal health insurance law, according to a new poll, but consumers most directly affected by the law are significantly less enthusiastic.

The Globe reported that 69 percent of those surveyed backed the law while only 52 percent of those who have been affected by it did. Most residents didn’t want to scrap the law, although an increasing number said it was hurting some groups that it was supposed to help, like the poor, the uninsured, and small businesses.

The paper, however, left out a crucial stat—only 37 percent of residents who are affected by the law (that is, those who were uninsured, had to get insurance, or change coverage) actually support the law’s sine qua non, its individual mandate. Fifty-six percent of those affected opposed the mandate, while 6 percent said they didn’t know. An enforceable individual mandate is emerging as the centerpiece of any national health reform effort, so knowing the opinions of those people most affected is important in selling such a requirement to the American public—including the nearly 50 million now uninsured.

Those opinions are not often reported these days, since the press tends to unquestioningly accept the positive spin from the law’s numerous cheerleaders. In a report issued last December, the Foundation, which mothered the law into existence, noted:

The majority of residents even favored the individual mandate, a very controversial aspect of the new law. The survey found that nearly 60 percent supported the mandate, even though it requires nearly all residents to obtain health coverage.

Ah, the 58 percent figure! But where was the more telling number—the 37 percent affected by the law who did not favor the mandate? Not in the report.

Since the press has a penchant for official pronouncements, it’s not surprising that two stories NBC Nightly News aired in early January gave viewers the impression the law was an overwhelming success. “The health reform effort has exceeded the expectations of those who backed it,” correspondent Robert Bazell reported. To make his point, he featured a young woman with breast cancer who was now able to pay for treatment. But this woman’s story had already been told, in an upbeat 2007-2008 progress report published by the state’s Health Insurance Connector Authority, which governs the program. Bazell told his viewers: “With the experience of people like Jaclyn Michalos [the patient], it’s not hard to see why the program is so popular.”

Whatever residents think of the mandate and its tax penalty (this year about $1000), they have driven down the number of uninsured to roughly three percent of the population—the lowest rate of any state. And it has brought health care to people who didn’t have it before. “It’s easy to damn the whole thing, and I see the cracks,” says Meg Kroeplin, who heads Community Partners, a non-profit group in Amherst that works with outreach workers who sign people up for insurance. “But I see a ton of people who were told their whole lives they can’t have it and now they do.” Of the 432,000 newly insured residents, 76,000 got coverage from Medicaid, 169,000 qualified for state subsidized coverage, 148,000 got it from their employers, and the rest bought individual policies.

The cracks Kroeplin sees, however, raise questions about whether a system that relies on private insurance and public coverage with strict eligibility requirements can ever achieve universality and bring seamless, timely care to everyone. “Is care seamless in Massachusetts?” Kroeplin asks rhetorically. “No, it is not.”

Some people who need care will always be left out. Because the building blocks of Massachusetts coverage are disjointed, people still seek treatment at the state’s safety net hospitals and emergency rooms, which wasn’t supposed to happen as people became insured. The Globe just reported that more people are seeking care in emergency rooms, and that the cost of treating them increased by 17 percent from 2005 to 2007, a period that includes two years covered by the law. The problem, it seems, is more complicated than simply mandating insurance coverage.

The significant reduction in the number of uninsured masks the discontent from people who fall through Kroeplin’s cracks and whose voices are not always heard in the media, or in glowing reports from the Massachusetts health establishment. For starters, thousands of residents don’t have to carry insurance. At the end of 2007, some 204,000 people remained uninsured. Nine thousand were exempt for religious reasons; 127,000 didn’t have to buy a policy because the state ruled that their incomes were too low to afford one; 68,000 paid the tax penalty.
Elisa McKernan, who spoke at a Boston forum last year, said that her family had lots of health problems but could not afford coverage. The state fined the family. Experts expect that these numbers will rise as the recession lingers, raising an unpleasant question that has been absent from the public discussion: Who is more deserving of insurance in a less-than universal system?

Undocumented immigrants and the mentally ill often fall through the cracks, as do the 20 percent of residents on Medicaid who cycle on and off the program. Medicaid, called Mass Health, is one of the state’s building blocks. State Health and Human Services Secretary Judy Ann Bigby told me half don’t send in their paper work to comply with the “redetermination process,” but she adds most get coverage when they get sick because providers get them back into the system.

Other people go bare, although they have employer-provided insurance. Many workers still decline that coverage because they can’t afford their share of the premiums. But the state doesn’t let them apply for subsidized coverage, even though that may be a better financial option. This is done to prevent “crowd-out”—wonk talk for making sure workers don’t choose a more attractive and cheaper option that takes business away from the private carriers. So much for consumer choice.

And any system based on financial eligibility holds an incentive for enforced poverty. If people try to earn more money because they need it, they get bumped into a higher tier in the state’s subsidized coverage and either their cost sharing goes up or they lose coverage altogether. They must choose between earning more money or losing subsidized insurance. NBC Nightly News briefly mentioned the problem, reporting on a clarinetist with the Boston Ballet orchestra who took a semester teaching job, earned more money, and lost his insurance. Its reporting should have gone much further. As the Financial Times reported last July in a package on the ailing U.S. health system, enforced poverty is a Catch-22. The FT shows a way for American journalists to tackle a missing piece of the story on individual mandates.

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Trudy Lieberman is a fellow at the Center for Advancing Health and 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. Follow her on Twitter @Trudy_Lieberman.