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The Massachusetts miracle: can a state's plan for universal health care really please everyone? Is this the beginning of a new wave of policymaking?

Earlier this year, the Democrat-controlled Massachusetts legislature and Republican Mitt Romney agreed on a radical new plan to provide health-care insurance to all Massachusetts residents. The program, which will become effective in July 2007, aims to shift the state's health-care spending toward enrolling individuals in private insurance plans; and it will penalize both employers and individuals who fail to participate.

Universal health care is not a new concept in Massachusetts. In 1988, Gov. Michael Dukakis crafted an employer mandate approach to healthcare insurance as he maneuvered toward the Democratic presidential nomination; but strong opposition from business groups led to repeal before it took effect. This year's plan may have a different fat. One reason is cost. The state estimates that the plan's cost will total S1.6 billion Since most of the funds are already available to Massachusetts through existing state programs and federal funding, the law's sponsors only expect to need an additional $125 million annually. But the real appeal of the plan may be the revolutionary way that the sponsors combined parts drawn from both sides of the ideological spectrum. Still, large portions of the plan have yet to be finalized, and it remains to be seen whether this fragile new plan can survive intensive scrutiny and the weight of all the details still to be written.

A Different Course

While states such as Maryland and Vermont have passed controversial "Fair Share" bills this year to compel health insurance coverage by large employers like Wal-Mart, politicians in Massachusetts, with support from key Bush administration health policy officials, set a different course. The result is an unlikely mixture of liberal (universal coverage) and conservative (individuals participating in private health insurance markets) concepts for promoting health-care coverage. Instead of a more traditional approach to covering the cost of the uninsured by plowing billions of dollars of public funds into hospitals through uncompensated care pools, the Massachusetts plan will invest the money into approaches that will steer individuals into private health insurance coverage.

While the Massachusetts plan has the strong support of leading universal coverage advocates like Sen. Ted Kennedy (D-Mass.), it shares more than a little with competing approaches sponsored by business groups and conservative policymakers. In fact, both the structure of the bridge between individuals and insurance plans and the mandate prohibition in the Massachusetts law are very closely related to core concepts in the small business health plan legislation that the International Franchise Association has endorsed. For example, the "Connector," a tool to give individuals access to the same buying power as large employers, is analogous to the role that national associations will play in the SBHP bill. Similarly, the designers of the Massachusetts plan recognized that state health insurance mandates play a significant role in making health insurance too costly for small businesses and individuals, and they barred Massachusetts from adopting new insurance mandates.

And since the plan echoes key elements of the federal policy debates over health care, it is very possible that a successful implementation in Massachusetts could clear the way for historic bipartisan cooperation in Washington, D.C. as well.

How it Works

The plan tackles the problem of the uninsured in three stages. First, it will bring the more than 100,000 of the state's total uninsured population who are eligible, but not enrolled, for Medicaid benefits into the state's existing Medicaid program. All other individuals will be directed into private insurance markets. For individuals earning between $9,800 and $29,400, the state will provide a subsidy to offset the cost of private insurance; while the remaining 204,000 uninsured who earn more than $29,400 will be required to purchase insurance without a state subsidy.

The plan requires all employers to offer access to insurance, but the real mandate is on individuals to purchase private health insurance. Individuals will be linked to health insurance pools through the "Connector," a privately-run panel appointed by the state. All taxpayers will be required to include their health insurance policy number on their state tax return or face the loss of their state personal exemption. Businesses with more than 10 full-time employees, meanwhile, are required to offer "cafeteria" plans under section 125 of the Internal Revenue Code or pay an annual $295 penalty for each employee. While providing access to a cafeteria-style plan does not necessarily cost the employer anything, it does make it possible for individuals without employer coverage to purchase their insurance through the Connector with pretax money.

States Looking to Follow

Health insurance policy has been at the forefront of many state legislative agendas recently. Numerous states have debated "Fair Share" or health-care cost reporting legislation in 2006; and Maine and Vermont have initiated plans to curb the number of uninsured. Now, many other states are looking to the Massachusetts example. An ongoing health insurance debate in Indiana, for example, shifted toward the Massachusetts approach. And Michigan Gov. Jennifer Granholm has proposed subsidizing health insurance premiums for the uninsured through a Connector.

Other states that are looking to replicate the Massachusetts program include Connecticut, Minnesota, New York and Vermont; and, with Gov. Romney anticipated to seek the Republican nomination for president in 2008, the Massachusetts model may become the centerpiece of his national campaign, as well.

Will it Work?

It is too early to judge this plan a complete success, and many questions will remain unanswered until after the plan is fully implemented. Some critics, for example, have questioned whether the $295 penalty for employers is a strong enough club to compel participation when an employer's cost of offering health insurance can exceed $3,000 per employee. Meanwhile, others have raised concerns about whether employers will be legally responsible for the full share of an uninsured employee's catastrophic health care costs. And overall support for the plan might collapse if costs rise dramatically and new taxes or fees are required.

Beyond Massachusetts, this kind of bipartisan success might be difficult repeat. While Massachusetts has relatively few uninsured, states with larger uninsured populations or more people below the poverty line might not be able to afford the subsidies. And any attempt to pass more of the cost onto employers or individuals might generate too much political opposition.

If nothing else, expect that the Massachusetts experience will encourage other states to experiment with health policy. Similar state and federal experiments in welfare policy in the early 1990s led to enactment of historic welfare reform legislation in 1996, so the nation may be on the verge of a new and creative period of policymaking in health care insurance.

David French is vice president of government relations of the International Franchise Association. He can be reached at 202-662-0768 or
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Author:French, Davis
Publication:Franchising World
Geographic Code:1U1MA
Date:Aug 1, 2006
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