1. What, in your opinion, was the catalyst for Massachusetts taking such extraordinary legislative and regulatory measures to try and get all Massachusetts residents insured?
SENATOR MOORE: There were several factors that prompted the Legislature to tackle health care reform. First,
the Federal Government determined to no longer permit states to maximize Medicaid reimbursements by what was called Intergovernmental Transfers – a creative way that states matched federal money with little real state or private money. Massachusetts stood to lose about $1billion. Second, there was a growing bipartisan, executive/legislative consensus to reduce the number of uninsured and this was also something that federal officials wanted as part of the waiver renewal process. Third, the cost of uncompensated or “free” care was growing rapidly already surpassing the billion dollar mark and about 2/3 of those using the free care pool were working, but did not have insurance. Essentially, the motivation came from pressure by federal authorities, concern about rising health costs for the uninsured, and concern about the fact that the uninsured usually sought care that was delivered in a very expensive setting – hospital emergency departments. Of course, Massachusetts has a long history in health reform beginning with the first state to have a department of public health in 1868. In more recent years, the Dukakis reforms of the late nineteen eighties helped set the stage, even though the major component was later repealed. A major initiative in the mid-nineteen nineties covered more children and senior citizens. Our 2006 comprehensive reform is another, albeit major, step toward our goal universal coverage as a caring Commonwealth.
2. Some people just don't want to have health insurance. Is that a consideration in the insurance legislation?
SENATOR MOORE: A study conducted by the Urban Institute and funded by the Massachusetts Blue Cross Foundation told us that in order to get to universal health care, we would need to require all residents to have health insurance and to develop a subsidy for those who could not afford insurance. We believe there is sufficient research to indicate that people with health insurance live longer, are more productive workers, and are generally healthier. We have established penalties for those who don’t have insurance that involve taking away a modest personal tax exemption and placing any penalties in the fund to cover the uninsured and subsidize the insurance program for low income residents. But it is also important to remember, as our first Governor, John Winthrop, articulated in his “City on a Hill” sermon in 1630, that we are a “commonwealth,” with a civic responsibility to care for each other and a personal responsibility to help ourselves within our means rather than burden society unnecessarily.
3. It’s been said that in the U.S. we don't have a health care crisis; we have a health care cost crisis. In effect, anyone who truly needs care will not be turned away. How does this Massachusetts program help contain cost? What provisions does it include to ensure quality, not just access?
SENATOR MOORE: Frankly, I think we have both. People aren’t turned away in health emergencies, but we don’t do a good job in this country managing chronic care and promoting prevention and wellness. Our health system also needs to place greater emphasis on quality and safety. So we have a health care crisis as well as a cost crisis. We have taken several steps to contain costs and promote quality. First, we’ve established a Massachusetts Health Care Quality and Cost Council chaired by our Secretary of Health and Human Services. It includes experts on health care quality and safety and they have developed a work plan to promote quality and contain costs, not just in the new low cost health insurance programs, but for all health care. The Quality and Cost Council was funded in the health reform law and provided with another one million dollar appropriation this year. A well qualified executive director has been hired and other staffing is now underway. Second, we have directed the Department of Public Health to develop a statewide hospital infection program following the guidelines of the Centers for Disease Control and Prevention and funded that with $1million last year and another million this year. We want hospital acquired infections to be a close to zero as humanly possible. Third, we have encouraged insurers to give credit for people in wellness programs or disease management programs so they get a financial incentive for doing the right thing. Finally, we have established a health disparities council to advise the Quality and Cost Council so that quality is the focus regardless of race, ethnicity, geography or other factors. We believe that the quality improvement and cost containment efforts are absolutely key to success of health reform.
4. Do you believe that other states will model similar efforts to get their uninsured into a similar plan?
SENATOR MOORE: Yes, in two ways. First, states have asked how we were able to bring disparate interests together to agree on a plan. So there is interest in the process of consensus-building as well as the product. Second, there are clear indications that states are interested in many of the components of our plan such as use of Section 125 plans to reduce cost of insurance, the merger of individual and small group insurance markets, the mechanism of the Connector, the individual insurance mandate, the quality and cost council, and so on.
California has told us that they are using many of our concepts in their planning. Many other states have contacted us about our plan. Some are using various features of our plan in their health reform efforts, and others tell us that they’re waiting to see if ours works before tackling the issue. No one will exactly copy our bill because states differ, and the cost and number of uninsured varies widely by state. We started with a relatively small percentage of our population without insurance – 7%. We also had money being used for emergency care for the uninsured that could be used to subsidize insurance for primary care for the uninsured. The important point is thatMassachusetts is demonstrating that states can play a leadership role in addressing the health care and cost crises. As Justice Louis Brandeis once wrote, states are the laboratories of democracy. State actions for health reform have raised the issue in the national debate as we approach a new presidential election, but most state leaders can’t keep waiting for the federal government to solve a problem that President Harry Truman first tried to tackle sixty years ago. Americans need affordable, accessible, quality health care now, and states are demonstrating that the goal is within reach. Our main concern is for the federal government to stay out of the way of states that want to reach the goal. We don’t need more regulations; we need less – like repealing some of the onerous features of ERISA. We also need federal resources to help share the financial impact and equalize the burden of economic and racial disparities.
5. Has there been much opposition to the law?
SENATOR MOORE: One year ago [August, 2006], there were approximately 372,000 uninsured residents in Massachusetts. Since then, 156,000 people have enrolled in Commonwealth Care, Commonwealth Choice or MassHealth [Medicaid]. Additionally, 1200 businesses have signed up for Section 125 plans through the Commonwealth Connector representing some 30,000 eligible employees who will benefit from lower cost insurance purchased with pre-tax dollars. Enrollment for part-time workers is expected to begin this October. An extensive outreach and information program is well under way. There has not, as yet, been any widespread opposition. In fact, there has been wide acclaim. Many people have told us how relieved they are to finally get health insurance that really provides benefits for care. Those who favor a “single payer” plan are critical because it’s not their plan and continues the employer based model. But a “single payer” plan simply is impractical on a single state basis, at least in Massachusetts. It would be unfair for the middle class – the majority of our taxpayers –since this group would bear the burden under our flat rate income tax. It would also be an open invitation for very sick people to move to our state without having contributed to the cost of their care. Such a plan is unsustainable in this state! The disruption to the economy resulting from raising taxes by billions of dollars, even though some would save some money dropping or curtailing insurance would be staggering. We need to remember that the “single” in “single payer” means all of us, not someone else, paying the bill in taxes! Even if “single payer” were adopted at the national level, many Americans would probably still want to have some insurance anyway just as they do in the single payer countries like Ireland, Britain, Canada, etc. When people who live in “single payer” countries don’t want to wait, they often go elsewhere and pay with insurance or out of pocket. The other group that has been critical is the “libertarians” who don’t think that government should have any involvement with the private insurance market. However, in health care the private insurance market – by itself – leaves too many holes in the social safety net. The cost and complexity of health care places it out of reach without government involvement through subsidies, regulations, and oversight.
Senator Richard T. Moore is the Senate chair of the Joint Committee on Health Care Financing
This program aired on August 3, 2007. The audio for this program is not available.