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. That law has become the blueprint for health system change on a national scale, and its advocates have aggressively marketed some variation of the Massachusetts plan as the reform of choice. There has been remarkably little analysis of how the law has worked. This is the ninth 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.

Early this fall, Robert Blendon and his colleagues at the Harvard School of Public Health, along with The Boston Globe, published one of those polls his gang has regularly been conducting since Massachusetts passed its health reform law in 2006. This year they found that, among those residents who had heard at least a little about the law, 59 percent voiced support while 28 percent opposed it; the rest didn’t know how they felt or refused to answer. A year ago, however, 69 percent supported the law and only 22 percent opposed it. In 2007, the numbers stood at 67 percent in favor and 16 percent opposed.

Support, it seems, as measured by the pollsters, is dropping. Blendon acknowledged the ten percentage point drop in support and blamed it on the state’s budget crisis. “There’s been a series of reports that health care is too expensive, the sales tax has increased, there are cutbacks in jobs and in schools. This has made people nervous,” he explained. “Health care is expensive here and costs are not controlled. If they can’t find a way to make it less costly, it will be an issue in next year’s gubernatorial election.”

This time, though, Blendon et al did not ask a more telling question—one he and his colleagues had asked residents last year. Then, in a poll done in conjunction with the Blue Cross Blue Shield of Massachusetts Foundation, they asked whether those affected by the law—that is, residents who were uninsured at some point, had gotten insurance, or changed their coverage—supported the individual mandate: the requirement that almost everyone must have insurance. Only 37 percent of those people said they supported the law, while 56 percent opposed it. In other words, those who had to buy a policy weren’t so happy.

Why not the same question, I asked? This year’s survey was done on a shoestring, Blendon said. His shop and the Globe paid for the poll. “I would loved to have had that question in the survey,” Blendon told me. The Foundation wasn’t interested in the topic, he said. It had already funded a different study examining what doctors
thought of the law. Surveying more people would have required a larger sample, which would have boosted the $20,000 cost to $40,000 or $50,000.

To take the peoples’ pulse another way, last week I interviewed men and women on the street in downtown Boston. Did they have insurance? What did they think of reform? How were they being affected by the law? Though not a scientific sampling, the survey offers some clues. Two things stood out: how little people knew about the law or even cared to know, and how many had insurance from their employers. Even before reform, Massachusetts had one of the highest rates of employer-provided coverage, and a large number of employers are still offering it. Were these insured folks ones that pollsters found supported the law? Was that all the more reason to know the answer to the question Blendon didn’t ask this year? What did people affected by the mandate really think?

Richard Darling is a homeless vet with no place to go. Darling said he lost his wife and his house when Katrina hit the coast of Mississippi four years ago. After the hurricane, he continued to work building warships down there, but then a year or so ago he got laid off. After losing a construction job a couple months later, he came back to New England to look for work. Darling, a fifty-five-year-old master electrician, says he has never been out of work before.

The conversation turned to health, and he laid his Mass Health card on the table. Mass Health is the state’s expanded Medicaid program, one of the building blocks of reform. Because he has no income, Darling qualifies. “It’s not worth a bean,” he said. “Not the plastic it’s written on.” He had tried to find a dentist to pull a bad tooth. One dentist said he wouldn’t do it, and sent Darling to another one who would accept his Mass Health card. The wait was at least ninety days.

Darling had run into smack into the state’s doctor shortage, and he didn’t like it one bit. Doctors look at you differently with Mass Health, he told me. “The guy who has regular insurance versus the guy who has Mass Health is going to be seen first.” He found the wait to see a doctor can be two or three months.

So he uses emergency rooms. He’s diabetic with high blood pressure, but did not appear overweight—one of the two percent of diabetics who don’t have a weight problem, he told me. Recently he waited hours in the ER at the University of Massachusetts Hospital in Worcester. They gave me a pill for the blood pressure, Darling said. “The streets have taken a toll on me.”

Christine Arentz was smoking a cigarette outside Borders Books. She works for the state Department of Public Health. “I don’t pay attention to the law,” she admitted. “I know it’s selfish.” She said that the department discourages employees from talking about the reform law anyway. “It’s not really about censorship,” Arentz explained, adding that they are worried people will say the wrong things.

Rocco LaMonica, age fifty-two, was standing inside the door at Borders. He works in loss prevention and customer assistance at the store, a job he has had for a year. Two years ago he was tending bar at a Boston food chain, but got laid off. “I was too fat, too ugly, and too old,” he said.

“I came here for the health insurance,” LaMonica explained. “I had to use it a couple of times. It’s a pretty good deal. He wasn’t sure how much he pays each month, but knows that it costs $25 for a doctor visit. I asked if he knew much about the reform law. “Not too much,” he said. “I know Uncle Ted was trying hard to push it through.”

Dao Nguyen, a twenty-seven-year old who works in finance at a wealth management firm, said she didn’t know much about the reform law. Nor did she know much about her own coverage from her employer, a Blue Cross Blue Shield policy: “I imagine it’s $100 a month, but I really haven’t kept track of it. Is that crazy? I mostly focus on what’s going into my account.”

She did know that, in Massachusetts, people are penalized if they don’t buy insurance. “From my understanding, it’s a pretty big fine for not having it—like $400 for not having it. It would be $400 a month.” (Actually, it’s about $1000 a year.) She did know there was something called Comm Care. A lot of her laid-off friends were turning to that.

Connie Green was on her way to her job as a housekeeper at the Copley Square Marriott where she has worked for twenty some years. She said she pays $39 a week for health insurance from the company, but was worried because Marriott had just changed insurers from Tufts to Cigna, and she wasn’t sure what that would mean. She also didn’t know what reform in the state means. I asked what she knew about it. “Not anything. I can’t say I do support it, and I can’t say I don’t.”

A fifty-nine year old man selling newspapers on a street corner wouldn’t give his name, but he knew a lot about the state’s reform law. He read the business section of the Boston Herald every day. Did he have insurance? “I can’t afford it,” he replied. Did he have to pay the penalty? “They haven’t caught up with me yet.” He did say that if things turned around, he might consider buying it. “But I am working in a dying industry. When the money comes back, then I’ll get interested.”

Between bites of Chinese barbecued pork, he talked about the law. “Good idea; bad implementation. They haven’t taken into account the cost of delivering the care or the extent of people needing the care. You can’t propose a program and not fund it.” Then he asked me a question. What did I think of the Republican drive to kill a public option? When I told him I had no opinion, he offered plenty more of his: “They already have socialism—Medicare and Medicaid. I can’t understand how people want to continue to be fleeced by insurance companies. They deny care and jack up the price. Supporting the public option doesn’t cost anybody a dime. It would force companies to compete.”

What does he do when he gets sick? “I don’t get sick. I stay healthy,” he told me. But when you do, I pressed? Last year he did have an ear infection. “I got it treated and paid the bill.”

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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.