John McDonough: Mass. Carved The Path, But More Needs To Be Done

One of a series of analyses on the 10th anniversary of the 2006 Massachusetts health care overhaul. John E. McDonough teaches at the Harvard T.H. Chan School of Public Health. In 2006, he was executive director of Health Care for All in Massachusetts. Between 2008 and 2010, he worked in the U.S. Senate on writing and passing the Affordable Care Act.  

Many believe that the 2010 Affordable Care Act (ObamaCare) was based on the 2006 Massachusetts health reform law (RomneyCare). It’s true, though only for the first section of the ACA known as Title 1, and not for any of the subsequent nine titles.

Title 1 took the Massachusetts model and used it to revolutionize U.S. private health insurance:

  • eliminating preexisting condition exclusions in all health insurance;
  • triggering the individual mandate;
  • providing federal subsidies to lower health insurance premiums and reduce cost sharing;
  • launching federal and state health insurance exchanges/marketplaces with websites;
  • and mandating larger employers to offer insurance or pay a penalty.

Clearly, this is nowhere as revolutionary as Bernie Sanders’ single payer proposal, but it represents the most dramatic set of changes in U.S. health insurance in 80 years.

Eliminating preexisting conditions, as well as lifetime/annual benefit limits and other unsavory health insurance rules, benefits tens of millions of Americans who will never know that they are helped by the ACA. More than 20 million Americans now have access to health coverage because of the ACA’s provisions. The ACA also represents the most important expansion of coverage and benefits for mental illness and substance abuse ever. Massachusetts carved the path. Still, the work of advancing affordable and quality coverage to all Americans is unfinished.

Much more needs to be done to improve the quality and efficiency of U.S. medical care delivery.  Though much has changed through the ACA’s Title 3 (e.g.: accountable care organizations, bundled payment, patient centered medical homes, hospital penalties for high rates of patient readmissions and adverse events), the full impact will take years as the U.S. health care moves away from fee-for-service and toward fee-for-value.

When I worked on the ACA as an adviser in the U.S. Senate between 2008 and 2010, I was often lectured by business and health industry leaders: “Don’t you dare do what they did in Massachusetts by only expanding access and not reforming medical care.”

Though Massachusetts’ 2006 law only addressed access, subsequent state laws in 2008, 2010 and 2012 placed the commonwealth as a leader on cost control as well, consistent with the forces set loose in the ACA.

2006 -- 2010 -- 2016: It is remarkable to contemplate the impact one state law had on the nation and on improving the lives of millions of Americans.

Health Law Turns 10: What Analysts Say:


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