Is National Healthcare Reform Repeating Massachusetts' Mistakes?

So where are we, as a nation, on health reform? You can compare the plans currently in play in an excellent summary here. But I can sum it up in two words: Massachusetts 2.0. Remember, MA was the first state to require all residents to have health insurance, with hardship exceptions. This was coupled with an employer mandate. It now has the highest percent insured population in the country, 97.4%. It is also drowning in healthcare costs, and looking for ways to cover them. The basis of its model: expand private insurance and use public insurance as a safety net. That has a familiar homey (or should I say House-y) ring to it, doesn’t it?

Given that Obama has studiously avoided talking about, much less praising, the MA effort, it’s ironic that Congressional efforts have mirrored this universal coverage pilot so closely. For instance, MA took the Congressional approach of tackling coverage first, and costs later. Nearly five years after its inception, MA universal healthcare is encountering steep resistance to proposed measures that would bend the cost curve, like Pay For Performance programs. As a result, insurance premiums continue to rise. They are expected to go up 10% for 2010. That’s not a good omen, as both chambers of Congress rely primarily on Medicare reimbursement cuts and pilot P4P programs to achieve cost savings.

More ominous yet, doctors in MA are cherry-picking patients based on their insurance plans. In MA as everywhere else, there is a shortage of primary care physicians. When demand is greater than supply, power shifts to those who provide the service. The complexity of the insurance behemoth wasn’t addressed during the MA overhaul, and it was in fact strengthened by a coverage mandate that did nothing to decrease insurance administrative bureaucracy. So doctors continue to pay for their correspondingly large administrative staff by preferentially seeing private plan patients. Some actually refuse to see poor patients on state-subsidized public plans.

Put another way, in 2008 20% of adults reported being told a doctor wasn’t seeing new patients or patients with their insurance plan. But poor residents (who receive free public coverage), or others up to 300% of the poverty level who selected subsidized public Commonwealth Care insurance, were TWICE as likely to be rejected as higher-income residents with private coverage. The benefits package in public and private plans is identical; it’s just the reimbursement that differs.

The House is following this model too – standardize benefits, but put the poor in Medicaid, the almost poor and riskier in the Exchange where they’ll likely choose a public option, the disabled in CLASS, the pre-existing conditions folks in temporary risk pools, and don’t let the currently insured switch from a private plan. Guess what we can expect from this “divide and conquer” approach? In MA, because of the provider cherry-picking, ER use for non-emergencies hasn’t decreased. Among low-income residents, 23% have used the ER for non-emergent issues, identical to 2006. That’s some very costly care.

From an employer-based insurance perspective, there’s actually good news out of MA. Contrary to fears, employers neither dropped coverage nor scaled back benefits. In fact, access to employer-based coverage increased, and employees rated the quality higher. The authors of the annual MA study, Sharon Long and Paul Masi of the Urban Institute, put it perfectly: “Although major expansions in coverage can be achieved without addressing health care costs, cost pressures have the potential to undermine the gains.”

So after so many months of debate, and with so many successful international models of universal healthcare to emulate, how did we get here? The simple truth is that reform has been in the hands of special-interest driven politicians who know nothing about healthcare. They are more focused on political positioning than fixing a crisis. Take Republican Mike Pence’s post on his website, denouncing the passage of HR 3962 and claiming "I am proud that all House Republicans stood by the American people in opposition." Facts be damned, apparently. Turns out Pence posted this gem hours before the final House vote. Thanks for declaring defeat in advance, Mike, and as for that solidarity play, well, big double oops.

So the blind and corrupt in the Beltway are leading the (mostly) just blind nationwide. ‘It’s politically expedient and it sounds good’ is not usually a recipe for success. MA deserves better than to see its challenges repeated, because it continues to work on its issues and share its lessons learned. If only our lawmakers would listen.

Note: MA actually has a leg up on D.C.: Commonwealth Care actually covers women’s reproductive rights.

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