Advocates for health care reform have been keeping an eye on Massachusetts, hopeful that its new health reform law will serve as a pilot program for the nation.
I’m much less hopeful than I was two days ago.
Yesterday I attended the Massachusetts Medical Society’s Eighth Annual Leadership Forum where I was one of four speakers. This year, the Society (which owns The New England Journal of Medicine) focused on the cost of health care –with a special emphasis on funding universal coverage in Massachusetts. The new was not good. While the citizens of Massachusetts believe that everyone has a right to health care (when polled 92% say “yes”), no one wants to pay for universal coverage. When asked “if the only way to make sure that everyone can get the health care services they need is to have a substantial increase in taxes [should we do it] 55% said “no.”
One speaker at the forum recalled a man who explained why taxpayers shouldn’t have to pick up the bill: “The government should pay for it.” (He didn’t disclose who he thinks “the government” is. )
Some citizens of the Commonwealth don’t even want to pay for their own
health care insurance. Under the plan, everyone in Massachusetts is
required to buy insurance (or pay a penalty), with the state providing
a 100% subsidy for those who earn less than 150% of the poverty level.
Those receiving the full subsidy are enthusiastic. The state had hoped
to sign up 57,000 uninsured and they’ve over-shot their target: 76,200
of Massachusetts’ poorest citizens have enrolled.
At the other end of the spectrum, the program isn’t doing as well.
Uninsured citizens earning more than 300% of the poverty level are
expected to buy their own insurance. Here, the state hoped that 228,000
of its uninsured citizens would sign up. So far, just 15,000 have
enrolled. Apparently, they’ve done the math and decided that it would
be cheaper to pay the penalty. But their premiums are needed to keep
the program going. If more in this group don’t sign up, it is not at
all clear how the state will be able to continue subsidizing the poor.
Yesterday’s first speaker, Robert Blendon, a professor of Health Policy
in Harvard’s Department of Health Policy and Management, talked about
what Massachusetts experience might mean for the national health care
debate: “Massachusetts is the canary in the coal mine,” Blendon
declared bluntly. “If it’s not breathing in 2009, people won’t go in
“If it looks like it’s not possible to reach an agreement on how to
fund universal coverage, politicians will walk right on by,” Blendon
The political cost of trying to put together a plan for national health
reform and failing is just too high for anyone to want to be involved,
he explained. “The Clintons understand this. They tried; they failed,
and they lost Congress.”
“When 2009 or 2010 comes, where will we be on healthcare reform?”
Blendon asked, and then answered his own question. “I think most people
are in a delusional state in terms of what they think will be going on
at that point. They think that the war in Iraq will be over, that we’ll
all be celebrating. I think that by 2009 or 2010, the climate will be
poisonous. The big question will be ‘Who lost the war in Iraq?’
“At that point, will there be an issue that can bring people together?”
he continued. “Will it be universal care? Or will universal care be a
divisive issue? “
Blendon pointed out that, even in Massachusetts, support for funding
breaks down along party lines, with Republicans strongly opposed to tax
increases—and there aren’t that many Republicans in Massachusetts. If
the Massachusetts plan unravels, he asked, “what conclusion will
politicians in Washington draw? If they can’t do it in Massachusetts,
how can we do it?”
Yesterday morning, Blendon predicted: “There is a very good chance that
the SCHIP veto will be sustained.” And universal coverage for children
enjoys huge public support. If Congress can’t override a veto on SCHIP,
will it ever have the votes (or the spine) needed to fund national
The morning’s second speaker, Dr. Steven Schroeder, a distinguished
Professor of Health and Health Care at the University of California,
San Francisco was almost as pessimistic. His talk was titled “Rising
Medical Expenditures: The Achilles’ Heel of the Massachusetts Health
Experiment,” and he began by analyzing why health care spending in the
U.S. is so much higher than anywhere else in the world.
It’s not because the baby-boomers are aging, he pointed out. Thanks to
the many new immigrants in this country, we have a younger population
that many developed nations.
The problem he said, is first, that our “fee for service system”
encourages both doctors and hospitals to “ do more. “ As a result,
Americans undergo more expensive procedures and our health care
providers use more expensive technologies. American believe that more
care is better care—and they demand it. Finally, there is no real cost competition in our marketplace.
Schroeder then went on to explain that just as the U.S. spends more
than any other country in the world on healthcare, Massachusetts spends
more per person than any other state. Yet it doesn’t have the highest
quality of care in the nation—far from it. Will Massachusetts be able
to contain health care spending and makes its universal health care
plan affordable? Schroeder wasn’t hopeful.
This week-end I’ll post again, describing what the third speaker,
Michael K. Gusamo, Asst. Professor of Health Policy and Management at
Columbia’s Mailman School of Public Health had to say when comparing
heath care in the U.S. to other countries, and finally, my own reasons
for believing that, if we have the political will, it’s possible to
slow health care spending and create a sustainable, affordable health
care system—and why Massachusetts is not the place to begin the