Massachusetts health care has lessons for other states

The Philadelphia Inquirer (MCT) - Many here say the state's experiment in health-care reform is a great success. The governor said last week that 97 percent of residents had health insurance _ the highest percentage in the nation.

But now comes Round 2: controlling health-care costs.

The state can hardly require people to buy insurance _ a foundation of the program _ if they cannot afford it.

"Once you take on this cost issue, it's going to get down and dirty," said Paul Hattis, a Tufts University doctor and member of the Greater Boston Interfaith Organization, which pushed for initial reform. "The dollar has to come out of somebody's pocket."

All this has implications for the nation. President Obama is trying to do both at once _ expand access to cover 46 million uninsured Americans and control costs.

Some here say he is doomed if he tries to do it that way.

"We did it right in Massachusetts. That's the most important lesson," said Stuart Altman, a health-policy expert at Brandeis University. "The first part was cover everyone, make it work. ... Trying to control costs brings every constituent group out against you."

The hope here now is that groups that came together to extend coverage to 436,000 residents will have a stake in preserving those gains and will back plans to control costs.

Exactly what was created?

Bipartisan health legislation passed in April 2006.

The state compelled everyone to have insurance. It was presented nobly as health care for all, and people embraced the concept. Even the Boston Red Sox did television commercials for the plan.

Under the law, young adults up to age 26 were permitted to remain on their parents' plans. Businesses with 11 or more employees that did not offer insurance were required to pay $295 per worker to the state.

To help people obtain insurance, the state created the Commonwealth Health Insurance Connector Authority.

This authority offers subsidized plans to residents who earn too much to qualify for Medicaid but not enough to afford insurance on their own _ up to $32,200 for an individual, and $63,000 for a family of four.

So far, 170,000 have joined this subsidized plan, known as Commonwealth Care.

Many pay nothing, essentially getting free care. Others, depending on their incomes, pay $39 to $140 a month.

Daniel Forlano, 33, a performance artist who works in front of Quincy Market, had never earned enough passing his hat to afford insurance. He felt he was young and healthy and did not need it. Why spend money on something he would never use?

But he sent in forms and qualified for free care. "That totally worked out," he said.

Hurmon Hamilton, senior pastor of the Roxbury Presbyterian Church in Boston, said 17 members of his congregation _ working people who previously could not afford insurance _ got coverage through Commonwealth Care, including one woman who had not visited a doctor in 17 years.

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When she went for her first checkup, doctors found a tumor that if not detected could have become life-threatening.

"Health-care reform saved her life," Hamilton said.

Steve Crawshaw, 48, of Framingham, a Boston suburb, lost a computer job in November.

"The HR manager at my company that laid me off told me about the Connector," he said of the new agency. "That led to a lot of surfing of Web sites, phone calls. Nobody knows the whole system in the government. So it's cumbersome. It's clumsy. ... Getting to where I am now took a lot of work."

Crawshaw and his wife pay $39 a month each, with no dental coverage, and he cannot use his family doctor. He is grateful but thinks what Massachusetts has done so far is not a solution, just cost-shifting _ moving the burden from his employer to taxpayers.

Kate Bicego is help-line manager for Health Care for All, an advocacy group. She answered the organization's hotline before the health-care overhaul and still does.

"We're just so blessed to have this option to tell people about," she said. "In other states, these people would fall through the cracks."

Some people still do.

Michelle McElroy, 34, who also lives in Framingham, lost her job last month. She was making $42,000. Her husband earns slightly more as a self-employed Web designer.

On one income, the couple still earn too much for subsidized Commonwealth Care. McElroy shopped online for private insurance but did not like any of the plans _ or the fact that she is compelled by law to buy one.

She expected to continue with insurance coverage from her former employer, as allowed under the federal COBRA law. Federal stimulus money will pay 65 percent of that cost for nine months.

Jon Kingsdale, executive director of the Connector Authority, said people whose incomes were too high for Commonwealth Care could buy affordable private insurance through his agency.

Insurers submit bids to the Connector that meet minimum standards, including a drug benefit. These are called Commonwealth Choice plans.

According to the Connector Web site, the cheapest plan for a Framingham couple, both 34, is $442 a month, with a $4,000 deductible and a $500 co-payment for each hospital night.

This year, the state will impose a $1,065 fine on people who can afford insurance but do not buy it. Since 2007, the state has collected $16 million in fines.

Residents such as McElroy can seek exemptions if affordable insurance is not available; the state has guidelines and 70,000 were exempted from the law last year.

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Robert Blendon, a health-policy and polling expert at Harvard University, put public support for health reform at 75 percent.

But he agreed that "the plans do not leave everybody happy. ... There is a problem for people on the margins. That is why the margin will be a hard sell nationally. ... Many more people live in that income range nationally."

The subsidized Commonwealth Care program was budgeted at $472 million in 2008 but ended up costing much more _ $628 million _ as enrollment grew faster than expected. The state budgeted $869 million this year.

So far, the state has not had to raise taxes to pay for the subsidized program. But it is also facing budget shortfalls of $4 billion from the economic crisis. As people lose jobs, the number applying for Commonwealth Care could grow.

Pennsylvania officials say a Commonwealth Care model is not realistic because the Keystone State has more than a million uninsured residents and lacks the resources to subsidize insurance for them.

The Rendell administration's sweeping efforts to expand health insurance stalled last year in the state Senate. In Gov. Ed Rendell's current budget, he is hoping to expand AdultBasic, a state-subsidized insurance program by 16,000. Currently, AdultBasic serves 44,000 people, with a waiting list of 205,000.

Tom Traylor, vice president at Boston Medical Center, which cares for more poor people in Massachusetts than any other hospital, says that covering people under Commonwealth Care was a good idea but that, overall, health reform has weakened his hospital.

In part because of the cost of health reform, Traylor says the state cut its Medicaid reimbursement rate to the hospital and jeopardized care.

He asks: What good is giving people insurance cards if the place they get care is worse?

Some critics are advocating a single-payer system in which the government would pay doctors and hospitals, and commercial insurers would have no role.

"One thing that is completely clear _ this (Massachusetts' program) is not a solution," said Steffie Woolhandler, a Harvard professor and cofounder of Physicians for a National Health Program. "We don't have universal access to care, and we're spending a lot of money to have a very mixed result."

"In my own practice last week," she added, "I had two people come in. One was literally crying. She had gotten free care under the state's free care program, and switched into the state's insurancelike program, and she was crying because she couldn't afford care. (She had co-pays now, and premiums.) Another patient came in and had gotten new insurance, and he was happy about it."

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One problem virtually everyone agrees on is the shortage of family-practice physicians _ a consequence of insuring 436,000 more patients.

Sarah and Nick Newlin, 38, moved to Boston last fall and were told they would have to wait eight months for an appointment with a family doctor.

"We actually got lucky," said Sarah Newlin, walking with her husband and baby in a stroller through Boston's North End. "We got somebody to see us at a clinic within four months."

"I think it's great," she said of the health-care program. "But looking at it nationally, they're going to have to do something about the supply problem."

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WHO ARE THE NEWLY INSURED IN MASSACHUSETTS?

About 150,000 residents bought insurance through employers after previously choosing not to buy it.

An additional 76,000 signed up for MassHealth, the state's version of Medicaid, known in Pennsylvania as Medical Assistance.

Almost 40,000 bought insurance through individual plans on the open market. Half of those purchased plans that are regulated by a new state agency, the Commonwealth Health Insurance Connector Authority.

Nearly 170,000 residents earn too much to qualify for Medicaid but are deemed too poor by the state to buy insurance themselves. They receive subsidized health insurance under Commonwealth Care, also run by the Connector Authority.

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© 2009, The Philadelphia Inquirer.