"Raising the Bar for State Health Reform" by Alan Weil

Amidst all the debate about the merits of the Massachusetts health reform law, it is easy to forget that its accomplishments have been nothing short of spectacular. A study authored by Sharon Long of the Urban Institute showed a fifty percent reduction in the number of residents without health insurance. Along with coverage came improved access to health care and a reduced financial burden associated with receiving care. These results were generated in just one year.

I can think of only two other state-level reforms that have had similarly dramatic effects. The first was Hawaii’s employer mandate, enacted in the mid-1970s with implementation delayed until the 1980s due to legal challenges. Under the Hawaii law, employers are required to provide health insurance coverage to their employees, but not their dependents. For more than a decade after enactment of the mandate, Hawaii had one of the lowest rates of uninsurance in the country. The second was Tenncare, implemented in 1994, which vaulted Tennessee from high levels of uninsurance typical of southern states to one of the lowest rates in the country.

Hawaii and Tennessee have lost their places of leadership in health insurance coverage. The Hawaii mandate is frozen in time due to federal law, making modifications that are more appropriate to the 21st century impossible. Tenncare has been dismantled and the number of uninsured in the state has grown.

Others draw the lesson from these two states and others that state-based reform is doomed to fail. While I would be the first to say that there are limits to what states can accomplish, it seems more valuable to seek to learn from the lessons of Hawaii and Tennessee.

The key lesson from Hawaii is that reform that cannot change with the times cannot keep up with the dynamic health care system. The key lesson from Tennessee is that expanding public coverage (Medicaid) without sufficient state resources to sustain the coverage assures the program’s eventual demise. Massachusetts leaders seem well-poised to avoid both of these problems, although the latter is surely a risk.

We all benefit from a healthy debate over the design and implementation of the Massachusetts reform. But ideologues and partisans would do well to remind themselves that the primary goal of the reform was to achieve nearly universal coverage and that the program has made extraordinary progress toward that goal. Indeed, progress this dramatic seems to come along at most only once every decade.

Alan Weil
Executive Director, National Academy for State Health Policy