If there’s a model for how President-elect Barack Obama’s health care policy
could play out in the real world and the political challenges it faces, look no
further than Massachusetts.
While Obama has been vague about the details of his health plan, the next
administration’s health care designs reflect what has been put in place in
Massachusetts since then-Gov. Mitt Romney signed a universal health care law in
2006. Both plans leave the employer-based health care system alone while
providing individuals access to cheaper insurance rates in the group market and
penalizing employers that do not offer health insurance.
There is, however, one key exception: Unlike Massachusetts, Obama has not
supported a law requiring individuals to purchase insurance—a politically
fraught policy that is nonetheless seen as crucial to the success of
Massachusetts’ effort.
“We have internally described [Obama’s plan] as ‘Massachusetts light,’ ” said
Michael Thompson, principal in the human resource services group of
PricewaterhouseCoopers.
By ditching the mandate for individuals to purchase insurance, Obama may have
removed a political stumbling block. But in its absence he would have to contend
with the consequences.
“I’m sure politically, the incoming administration would like to stay away
from an individual mandate,” said Jon Gabel, a senior fellow at the National
Opinion Research Center in Washington. “But I have a hard time figuring out how
it will work without an individual mandate, and I think others think that
too.”
Researchers say initial evidence shows the Massachusetts plan has achieved
its primary goal of reducing the number of uninsured. And contrary to employer
concerns, workers have not fled employer health plans for government-sponsored
ones.
Also confounding expectations, few employers have opted to pay the penalty of
$295 per employee, choosing instead to invest in the more expensive option of
providing health insurance for employees.
Researchers believe the use of mandates—both for individuals and
employers—played a key role.
Employer and individual mandates gave companies an incentive to offer health
benefits. Rather than pay a fine to the government—and since employees must find
insurance anyway—employers that invested in health care could comply with the
law and look good in the eyes of their employees.
Also, because of laws prohibiting health insurance companies from excluding
people with prior health conditions, the individual mandate kept
people—especially the so-called “young invincibles” who are healthy and don’t
use health care regularly—from purchasing health insurance only once they get
sick. That would have left employers and the government to insure only the
perennially unhealthy who are the most costly to insure.
The success of these mandates came only because major constituents stayed
focused on making concessions in order to reach consensus, said Jim Klocke,
executive vice president of the Greater Boston Chamber of Commerce.
“There was a guiding principle all the way through that a lot of the biggest
strategic players had, which was to keep everybody at the table,” Klocke said at
a recent roundtable on the lessons of Massachusetts health care reform sponsored
by the Commonwealth Fund and the Alliance for Health Reform.
Exporting the Massachusetts plan to the rest of the country is a significant
political challenge, especially in areas where libertarian views among
individuals and employers run high.
The challenges don’t end there, either.
“We’ll have a problem if we don’t address the underlying cost of health care
as we address access,” Thompson said.
On that point, the Obama plan also resembles the Massachusetts model.
“It’s worth noting that Massachusetts made the decision to go forward and
expand health insurance coverage knowing they were not addressing the cost
issue,” said Sharon Long, principal research associate at the Urban Institute,
during the roundtable.
Having postponed discussions around cost, the state now must grapple with
paying for the health care program at a time of severe budget deficits. In its
first year, the Massachusetts plan cost $153.1 million more than the $472
million appropriated.
And enrollment is growing faster than expected. Annual state spending could
top $1 billion by 2009 if participation in the state-financed health insurance
system reaches 255,000 residents. As of May, enrollment stood at
175,000.
—Jeremy Smerd