Considering Mass. health care reform as a national model

Heller study appears in current issue of Milbank Quarterly

Michael Doonan

On Tuesday, President Obama signed into law U.S. health care reform legislation, leaving many Americans wondering how it will affect them, their families, and their businesses.

A new study in the Milbank Quarterly by Brandeis health policy experts reports that critical lessons can be learned from the Massachusetts experiment. The study was based on interviews with key stakeholders, state government representatives, and officials from the Commonwealth Health Insurance Connector Authority.

The national health care reform bill was modeled on groundbreaking 2006 legislation in Massachusetts requiring all adults in the Commonwealth to have health insurance coverage through an individual mandate. The study explains how Massachusetts has handled the insurance requirement since 2006 and describes the lessons policymakers have learned.

“The individual mandate is the linchpin to making health care reform work, said lead author Michael Doonan, assistant professor at the Heller School. "The individual mandate forces you to define affordability, coverage limitations, and other key aspects of any successful health care reform. Moving towards universal coverage makes it possible to prevent insurance companies from discriminating against people with pre-existing conditions.”

Massachusetts has a head start on addressing some of the issues that will now surface on the national level and on a state-by-state basis. In Massachusetts, most people still receive insurance through their employer with no changes. The previously uninsured are covered through the expansion of existing subsidized health care programs such as MassHealth (the state’s Medicaid program), the Children’s Health Insurance Program, and the employer-based Insurance Partnership Program. New programs, such as Commonwealth Care, were also created. Reforms also led more people to sign up for coverage at work or to purchase coverage through the new exchange, the Commonwealth Health Insurance Connector Authority.

Massachusetts enforces the insurance mandate by requiring residents to file proof of health insurance with their annual tax forms. Residents who cannot afford insurance may obtain a waiver, but most have not done so. Currently, ninety-seven percent of Massachusetts adults are covered--the highest number in any state in the nation. The largest increase in enrollment was implemented through the Commonwealth Care program, which allows those with a family income under the 300 percent federal poverty level to receive subsidized insurance. The Massachusetts mandate also limits the ability of insurers to exclude pre-existing conditions from coverage.

“While Massachusetts, like the rest of the country, still has problems with rising health care costs, this program greatly expanded coverage and access to health care services," said Doonan. "The program also reduces the fear that insurance companies will drop coverage as soon as you get sick.” Overall, said Doonan, the program enjoys strong public support in part because of ongoing stakeholder engagement including consumers, hospitals, insurers, the business community, and others.

Now that legislation at the national level has passed, the critical implementation stage begins, and how this is handled will determine the long-term fate of health care reform in the United States, the study concludes.

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