How They Would Change
Health Care: Obama
Obama's Approach Emulates Massachusetts's
Except for Mandate on Covering All Adults
By Amy Goldstein
Washington Post Staff Writer
Wednesday,
October 29, 2008; A01
BOSTON -- On the ninth floor of an office building just off the Boston Common, a group called Health Care for All runs a help line
that, not long ago, got 40 calls a month. Today, the calls each month have
swelled to 3,000, as people throughout Massachusetts phone in for guidance in
navigating a state experiment in health reform that is the most ambitious in the
country -- and a test of Sen. Barack Obama's vision for reshaping health care
nationwide.
Kate Bicego, the help line's manager, slipped on her headset one recent
afternoon as a call came in from Travis Lynn, a 26-year-old from Jamaica Plain
with asthma and a part-time job at an old movie theater. He wanted to renew his
enrollment in Commonwealth Care, government insurance that Massachusetts now
offers adults who cannot get coverage through their work or afford it
themselves. After a few questions, Bicego told him: "So, it sounds like you will
still be eligible . . . premium-free, with vision, dental and medical."
Lynn is one of 439,000 people here who have gained insurance since
Massachusetts embarked two years ago on a path to near-universal coverage. More
than half of them are paying toward it; the rest, like Lynn, get it free. How
close Massachusetts can come to its goal -- and what obstacles it encounters --
is significant, because its strategies resemble much of the approach to health
care that Obama has said he would pursue if elected president next week.
Obama says he would keep the familiar arrangement in which most Americans get
health insurance through their jobs, as Massachusetts is doing. Yet he also
favors profound -- and controversial -- changes that Massachusetts also is
putting in place: Expanding government insurance programs and subsidies.
Requiring employers to offer their workers coverage or face penalties if they do
not. Forbidding insurance companies to reject anyone or charging more if they
are sick. Creating a national health insurance exchange to help people to find
and compare private insurance policies on their own.
In the most significant departure from the Democratic nominee's thinking,
Massachusetts has imposed a mandate that requires most adults to carry health
insurance -- and fines them if they refuse.
In the 31 months since the experiment here began, the share of working-age
people without health insurance has plunged -- from 13 percent to 7 percent by
one estimate -- more sharply and quickly than anyone expected, leaving
Massachusetts with the lowest uninsured rate in the country. But the unexpected
number of people also has translated into higher-than-expected costs.
Massachusetts has been forced twice to scrounge for extra money, totaling more
than $250 million this year and last, from state funds and other places.
There have been more unintended consequences. The large number of people who
have gotten insurance and are suddenly looking for care has aggravated a
shortage of family physicians and other primary-care doctors. A reshuffling of
federal and state money, to help pay for the extra insurance, has pulled funds
away from some hospitals and clinics that have long been havens for poor
patients.
Hard as it was to enact Chapter 58, as the health-care law here is known, the
work of putting the plan into practice is proving even more rigorous, according
to state officials, business leaders, health-care providers and community
activists. The law left unanswered polarizing questions, including who should be
eligible for subsidies, what benefits must be included and whether some people
should be excluded from the mandate.
"It isn't like you come up with a perfect plan and turn it on and see how it
works," said Brian Rosman, research director at Health Care for All, the
nonprofit that runs the state's largest private health help line. "Washington
needs to understand that as well."
"This is all really a journey," said Nancy Turnbull, an associate dean at the
Harvard School of Public Health and member of the governing board
of the Health Connector, a new agency created out of the law. "Every time we
make one of these decisions, we take a leap of faith."
Whether what is unfolding in Massachusetts could be replicated in Washington
during an Obama administration is, people here say, an open question. The law
that emerged in 2006 from the gold-domed statehouse on Beacon Hill was the product of an unusual alignment of outside
forces, motivations of key players, and the local health-care climate.
Massachusetts's lawmakers had been warned that federal health officials would
take away $385 million a year in money for poor patients unless the commonwealth
found a different way to spend it. And on the streets of Boston, an influential
coalition -- community activists, hospitals, doctors, unions and hundreds of
religious groups -- had gathered signatures for a popular ballot initiative
that, if the legislature did not act, could have rewritten the state
constitution to make health care a right.
Then-Gov. Mitt Romney, a Republican on the cusp of his own presidential
campaign, was calling for a "culture of insurance" as he sought tangible
accomplishments. At the same time, Massachusetts faced a smaller challenge than
much of the country, with fewer uninsured residents to start with and fewer
undocumented immigrants, who cannot qualify for help.
Even under such favorable circumstances, Chapter 58 was stalled in the
legislature for months, as businesses balked at the prospect of penalties for
not insuring their workers. That fractiousness was still in view the April 2006
day that Romney staged a theatrical bill-signing in historic Faneuil Hall; he
vetoed that part of the law, although lawmakers later restored it.
The Health Connector -- similar to the health exchange Obama envisions to
help people shop for private health plans or a new public one -- was created to
run the new programs and shepherd the reforms. One of its first tasks was to
spread the word that Massachusetts now required insurance. It set up a booth at
Boston's beloved Fenway Park. Banks, supermarkets, buses, cable television and
grass-roots groups chipped in. Buying health insurance "is a grudge buy," said
Jon Kingsdale, the Connector's executive director, "that has to be actively
sold."
The sales pitch worked better than imagined, because the state had
underestimated how many people were uninsured. After the first year, 176,000
people -- 40,000 more than predicted -- had rushed into Commonwealth Care, the
program Lynn joined that provides free coverage or subsidies.
Even now, some residents go without health insurance. Some are offered
coverage through their jobs but cannot afford it. The law does not allow
subsidies for them. In fact, the Connector board agreed to exempt from the
mandate about 60,000 people, some in that group and others with incomes too high
for Commonwealth Care but too low for private insurance.
The effect of requiring insurance, the biggest difference from Obama's plan,
is a matter of debate. Neera Tanden, his campaign's director of domestic policy,
said of his plan, "With a mandate or without a mandate, we are dramatically
expanding coverage."
Here in Boston, the common wisdom is different. "The mandate has been an
overwhelming influence," Kingsdale said. The price of refusing to get insurance
is climbing: from a $219 tax penalty for 2007 to as much as $900 this year.
Last year, MabelSarah Lubogo, 43, a certified nurse's aide who rents a
one-bedroom basement apartment in Belmont, paid the $219, figuring it was less
than the price of insurance. She used to get coverage through an office job.
When she switched work four years ago, she looked for a policy by herself but
found them too expensive. Last year, she went to a hospital emergency room twice
with unexplained fevers -- leaving her with $4,000 in bills she still is paying
off.
This year, a letter arrived from the state saying Lubogo would be fined $75 a
month if she didn't get insurance. She called a phone number she saw on
television and signed up for a Commonwealth Care plan that costs her $167 a
month. With fibroids that need treatment, she said, "I'd rather have something
to help me along."
Across Massachusetts, there has been little hint of backlash against the
requirement. Public support for the law, high when it passed, has risen since
then, surveys show.
The mandate on individuals appears to be having a greater effect than the
pressure on companies. "Fair share" fees that businesses must pay if they do not
offer coverage are substantially smaller than the cost of helping workers with
insurance premiums. The proportion of Massachusetts companies providing
insurance, higher than in many states, has barely changed.
The largest lingering question here is whether Massachusetts, having already
made big strides in insuring people, can solve the more intractable problem of
health-care costs. Chapter 58 "didn't do anything with cost containment," said
Massachusetts Senate President Therese Murray (D). "We can't sustain the costs
the way they are."
This year, Murray pushed through a second phase of health reform, intended to
constrain spending and expand the supply of primary-care doctors to take care of
newly insured patients. Debate still swirls whether this second law, two months
old, will help.
In the meantime, the emphasis here on insurance is producing results,
imperfect as they are at times. Travis Lynn, who renewed his Commonwealth Care
coverage through the help line, was dismayed last winter when the program
dropped him because he briefly had a higher-paying job. It took him months to
get his coverage back, even though he had quit that job because he was unable to
walk for weeks after surgery he needed from stepping hard on a plastic champagne
glass at a New Year's Eve celebration.
Jaclyn Michalos believes Commonwealth Care saved her life. A waitress and
high school field hockey coach who will turn 29 next week, she had a teaching
job right out of college that came with insurance. After she left teaching, she
signed up for a policy on her own. It cost $500 a month, nearly one-third of her
income. As soon as the first bill arrived, she wrote to the insurance carrier to
cancel it.
So Michalos had been uninsured for two years when she noticed a lump in her
left breast. "I saved up my money," she said, and went to a doctor, who told her
not to worry about it. Still, the lump persisted, and a few months after
Michalos joined Commonwealth Care, she went for a physical with a new doctor,
who referred her for tests that diagnosed her breast cancer.
Commonwealth Care covered her double mastectomy and silicone implants. She
did not pay a thing.
© 2008 The
Washington Post Company