Universal Health Care: The Diagnosis (page 2 of 3)

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Stephen Gore was battling kidney cancer when he signed up for the plan.

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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.

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