I’ve been travelling and so missed the release of Health Wonk Review #5 on April 20. Never too late to check out this overview of health policy commentary and analysis from the health blogosphere. Click here to see the latest. Well worth a look.

Today’s Wall Street Journal contains results of national polling that tests US public support for the new MA health reform approach. Here’s the proposal respondents were asked to rate:

“Make it mandatory for every person to have health insurance. People with higher incomes who do not have coverage would be required to buy insurance, and the government would help to pay for insurance for those who cannot afford it.”

Strongly Favor 50%
Mildly Favor 18%
Feel Neutral 9%
Mildly Oppose 9%
Strongly Oppose 12%
Not Sure 2%

What’s surprising? Details show Democrats and Independents like this more than Republicans do. Interesting that only 2% have no opinion. Overall, action health care is the #3 national priority in the poll after gas prices and the Iraqi War.

The California Health Care Foundation just released a report estimating a $9.4 billion cost to implement the MA health reform model in the Golden State, $1450 per uninsured resident. Not likely to be a winning formula. Click here for the study and here’s the summary:

In April 2006, Massachusetts became the first state to require all residents to obtain insurance. The plan has drawn national attention and sparked debate about whether a similar approach could work in California, which has 6.5 million uninsured residents—nearly 12 times the number in Massachusetts.

Massachusetts-Style Coverage Expansion: What Would it Cost in California? explores the costs of a similar approach in California. The analysis, by the Institute for Health Policy Solutions, finds that because of economic and insurance coverage differences between the two states, providing Massachusetts-style health insurance coverage in California would require as much as $9.4 billion in additional funding—or $1,450 per uninsured Californian.

Spending on premiums and out-of-pocket expenses for Californians under age 65 would rise 9.9 percent per year to just over $117 billion. Contributions from employers would increase 8.8 percent per year to $63.8 billion, assuming no changes in employers’ contribution policies. The rise in employer spending is due to a projected increase in enrollment by workers and their dependents who previously declined employer coverage.

The study notes several key differences between the two states. For example, the percentage of the population without health insurance in California is 20.7 percent, which is much higher than the 13.1 percent in Massachusetts.

I’ve previously recommended the Health Business Blog written by Boston-based David Williams at MedPharma Partners. One of the best of a good crop of health policy blogs. In response to

Monday’s Healthy Blog on Gov. Romney, the Wall Street Journal, and “guaranteed issue,” David offered his own thoughts on this topic, well worth a read and a visit. Thanks for the great posting, David! Keep checking out this useful and well written site.

“Guaranteed issue and community rating are attacked by critics as left-wing ideas, which drive up costs and interfere with the market. But in my own experience, these rules actually promote entrepreneurial activity (a capitalistic pursuit, last I checked.) ”

One additional thought — regardless of the source, Massachusetts is one of the top ten states with the lowest number of uninsured, even before health reform. If “guaranteed issue” were the disaster the Wall Street Journal suggests, wouldn’t we have a lot more uninsured than we do? And those “free market” states like Texas with more than 25% uninsured — if an unregulated market and medical underwriting are the answers, someone please tell me what the question is…

In the midst of all the health reform veto overrides, let’s take a minute to salute the House for overriding Gov. Romney’s veto of restored health benefits for elderly and disabled legal immigrants (section 27). In this season of immigrant bashing, the House deserves thanks and praise for addressing this issue forthrightly and quickly. There were a lot of folks who worked very hard for this victory — especially everyone involved in the MIRACLE coalition — and most especially my big sister, Judy Meredith, who poured her heart and soul into this one.

Here’s Judy’s on-the-scene report (names disguised to protect the innocent):

“Well it was a little anti-climatic, because there was no debate on section 27 — and it was the last veto and the next to last vote before they broke.I thought I had mis-counted the number of veto over rides because I had seen one rep in her seat watching closely, and I had seen the Republicans talking to her. So when I ran downstairs to double check, she was the one who told me it had just happened and that the Republicans (’the other side,’ she said) had asked to speak on it and she refused because they were legal, and as she leaned over to whisper in my ear gesturing between herself AND me, said ‘and they’re elderly and disabled.’ Maybe it is time for me to really retire.”

Not by my count, Judy.

New study from the Commonwealth Fund shows that the proportion of folks earning between $20K and $40K without health insurance is rising fast. This is the new frontier of the uninsured — folks in the “near poor” and lower middle income category. This is the group most at risk not to be covered in MA health reform. We’ll be watching closely and keeping you informed.

Here’s info on the new study, worth a look:

America’s uninsured crisis disproportionately affects lower-income working families. But new survey data show that moderate-income Americans are increasingly going without health coverage as well. According to Gaps in Health Insurance: An All-American Problem, a report prepared for the Commonwealth Fund, two of five working-age Americans with annual incomes between $20,000 and $40,000 were uninsured for at least part of the past year. This represents a dramatic and rapid rise from 2001, when just over one-quarter of this group was uninsured. The study finds that 21% of adults surveyed, insured as well as uninsured, are struggling to pay off medical debt, while nearly 60% of chronically ill adults with a recent time uninsured skipped medications because they could not afford them. The survey also found that the uninsured are more likely to go without recommended cancer, cholesterol, and blood pressure screenings. A Robert Wood Johnson Foundation analysis released today confirms similar trends in every state.

Just when we were so proud of ourselves for agreeing with Mitt (see Monday’s post on guaranteed issue), here we go again!

Read and weep in today’s Kaiser Daily Briefing:

Romney in a speech at the U.S. Chamber of Commerce on Tuesday discussed the new law and said critics likely will support the plan once they have studied it more carefully. Romney said, “They key factor that some of my libertarian friends forget is that today, everybody who doesn’t have insurance is getting free coverage from government. And the question is, do we want people to pay what they can afford, or do we want people to be able to ride free on everybody else. And when that’s recognized as the choice, most conservatives come my way.” Romney added, “Most impressions at this point are inaccurate or partially baked.”

Can we get this straight, please? “Everyone who doesn’t have insurance” is NOT getting free coverage from government. In Massachusetts, persons without health insurance are eligible for free hospital and health centers services only up to 200% of the poverty level (=$19,600 for an individual); folks between 200 and 400% of poverty are eligible for partial free care, after paying a large deductible. (And that’s probably the best deal for the uninsured in any of the 50 states.)

Folks without insurance over 400% of poverty (=$39,000 for an individual) become targets for collection agencies. They become part of the large army of Americans suffering under the crushing weight of medical debt, involving (depending on which survey you believe) between 18% and 50% of US personal bankruptcies. And that doesn’t even touch the huge numbers of folks with health insurance who are struggling with medical debt because of outrageous deductibles, co-pays, and other cost sharing.

Will someone from the media please, please take Mitt to task for this outrageous distortion?

The House this afternoon overwhelmingly overrode the Governor’s veto of four sections of the health reform bill. Another four sections remain to be voted on. All Democrats voted to override . The 21 Republicans generally voted to sustain vetoes, though they were divided on restoration of dental and other benefits.

Thank you, House. Please do it soon, Senate…

The provisions overrode were:

- Restoration of dental coverage, eyeglasses, and other benefits to adults on MassHealth (vote was 147-10)
- The employer Fair Share assessment on businesses that don’t provide coverage (vote was 135-20)
- Preventing changes in MassHealth mental health services until a report is completed (vote was 139-18)
- A study on the impact of the employer assessments (vote was 136-18)

Here’s some excerpts (from State House News) from the debate on two key overrides:

1. Benefits Restoration:

Rep. Walrath (D-Stow): The governor said he vetoed this section because it would cost $75 million and was unsustainable. We disagree with that estimate. We’ve done careful estimates, and that would amount to $42 million, reaching to a high of $52 million in FY09. All conferees agreed that they want those services back. When we cut those services, the eyeglasses, dental, it was not something we wanted to do. We had to make a lot of uncomfortable cuts. I was at a senior center in my district two weeks ago, and one lady came up to me and said, we’re going to get the dental back, aren’t we? I said, the governor vetoed it. And she started crying. That’s how important this is. They can’t get jobs if they don’t have teeth.

Rep. Rogeness: It’s difficult to ask that a benefit not be provided. It is ambitious to change the way everyone gets health care. We don’t know what the cost is going to be. We have our estimates. It seems unwise to add a benefit that has come and gone. This might cost $42 million, it might cost $75 million. It’s my experience most health care mandates go up in cost as time goes on. I hope you do not override this veto. It’s easier if we don’t have this mandate tacked on to a $200 million item.

2. Employer Assessment:

Rep. Mariano (D-Quincy): I hope the governor’s veto is overridden. This is a foundation of our plan. This section assesses all employees who use the free care pool. We have arrived at a number of those who have used the free care pool and haven’t contributed. Last year we spent about $620 million on free care in the state. We had employers use the pool to the tune of $279 million. Large employers: Friendly’s, Wal-Mart, McDonalds. This forces everyone to participate. We may hit disagreement, but it is an attempt to spread the cost and do more for employees than any other plan in the past. I hope it is overridden.

Rep. deMacedo (R-Plymouth): … I disagree on this jobs tax. I ask you to sustain the governor’s veto. Massachusetts is one of the most expensive places to do business in the country. We have the highest energy costs. We have the highest wages costs. We have the highest unemployment insurance costs. Now they’re talking about raising the minimum wage. We just heard about giving maternity leave to employees for 12 weeks. All these things have impacts on our business community, which creates jobs. … This is a $1.3 billion bill. This assessment for $45 million is so small that the need to do this is not imperative….This assessment will have a chilling effect on job growth in the Commonwealth.

Rep. Perry (R-Sandwich): I hope the governor’s veto is not overridden today. I’m one of two of us who voted against this bill. … Why don’t we start this effort without a new tax? Let’s try it. Let’s do everything else and let’s not do it with a new tax. … We’re losing people. And if we’re going to straddle people with a new tax and discourage people from coming here to do business, it’s not going to get better. … We should take the next step without imposing a new tax.

Rep. O’Brien (D-Kingston): … If you vote not to override the veto, you’re voting to have government bear the cost and provide health care. Everyone has to play a part. Everyone has to come to the table. The governor says individuals should come to the table. Hospitals should come to the table. But we don’t want employers to come to the table. It doesn’t make any sense….

Rep. Jones (R-North Reading) … I’ve heard members talk about how we need everyone to pay. I read the bill and I thought that everyone under 11 employees is exempt. When I look in the dictionary, everyone means everyone, no exemptions. … If you’re really looking for consistency, you’ve accepted the argument that this is bad for the economy by virtue of the fact that you’ve exempted employers with under 11 workers. A recurring question to me has been, why don’t these employers offer health insurance? Is it really the difficulty in competing because of the high cost of doing business? Don’t let the new math change the definition of everyone. It’s not right. It’s not accurate. And it’s not fair.

Rep. Webster (R-Hanson): … Many people suggest we lost the Taxachusetts tag. I certainly have not seen that. We continue to send the message to business that we don’t want you here. We tax any business more than most other states and we need to put a stop to that. We have the highest unemployment tax rate. Now we will tax employers for not providing insurance to their employees? … Government can not and should not be all things to all people. … Let’s stand up here today and let’s do the right thing and not send the message to businesses in the state that we don’t want you. The more jobs we create the more revenue we raise, and the more revenue we raise the more we can support those we represent.

Around 9pm, the House overrode the final four health reform vetoes by Gov. Romney. Brief SHN excerpts:

HEALTH BILL - WAIVER NEGOTIATION INFORMATION: Question came on whether to override or sustain the governor’s veto of section 112 health reform bill. Rep. Walrath said she hopes the veto is overridden. The governor vetoed this because he said it imposes inappropriate controls on the executive branch. The concern was the secrecy with which the administration conducted negotiations with the CMS. We weren’t able to get the papers we needed, the type of information we needed. It was a detriment to the best interests of the Commonwealth and impeded the resolutions we were trying to reach. The language requires the administration to consult with a member of the House and a Senate appointee.

BY A VOTE OF 137-19, VETO OVERRIDDEN

HEALTH BILL - PUBLIC HEALTH COUNCIL SECTION: Question came on whether to override or sustain the governor’s veto of section 5 Public Health Council. Rep. Walrath said this deals with the Public Health Council. The governor believes this gives private organizations the authority to appoint members and this violates separation of powers. House counsel does not agree. The language was crafted so that it did not. The work of the department is important and deserves diverse, excellent membership. The old provisions made very few demands on the governor. We expand membership to 18 members from nine including the five deans of the state schools of public health, six providers, long term care facilities and a variety of individual providers, six non providers with expertise in preventing medical errors, veterans health care, health care consumers and community outreach. I hope section 5 is overridden.

BY A VOTE OF 137-19, VETO OVERRIDDEN

Today’s Wall Street Journal editorial page attacks Mitt Romney and the health reform bill for not changing our state’s private insurance laws, especially our law requiring “guaranteed issue.” Here’s their charge — read and weep:

MA Gov. Mitt Romney signed a bill recently that’s being praised as a model for how to achieve “universal” health care. But while the governor claims his plan is market based, it does little to reform regulations that have made coverage in his state among the most expensive in the country.

How bad are Massachusetts’ insurance regulations? One good indicator is that it’s one of few states in which eHealthinsurance doesn’t sell policies in the individual market. eHealthinsurance is an Internet insurance brokerage that makes it easy for people in most of the 50 states to find out what kind of coverage is being offered in their areas. We tried to price coverage in the Bay State and came up empty. So we called the company to ask why. “Guaranteed issue,” was Chief Operating Officer Bob Fahlman’s instantaneous reply.

Guaranteed issue is the name of a regulation that requires insurance companies to sell policies to all comers, even those who wait until they’re sick to seek coverage. Naturally the requirement to accept free riders makes insurance more expensive for everyone else. It also means insurance companies aren’t eager to be found by consumers, even though they are generally required to sell in the individual market to be able to offer coverage through employers. Yes, you read that right, they don’t want customers.

So in Massachusetts, insurers hide, in part by refusing to pay commissions to brokers such as eHealthinsurance. Their prices are also a disincentive. An eHealthinsurance survey earlier this month found the Aetna HMO in Boston asking $1,719 a month to cover a young family of four, and $560 for one nine-year-old child.

The new Massachusetts health care legislation does little to address the root causes of this cost problem. Guaranteed issue is preserved. And while a new insurance regulation board could do something about other mandates, it’s not likely to do much in practice.

The $200 per month target price Gov. Romney talks about for the state’s new mandatory insurance is higher than 80% of the individual policies eHealthinsurance reported in a study of 80,000 customers nationwide late last year. The range of average monthly premiums for individuals was as low as $98 in Michigan and as high as $245 in New Jersey and $379 in New York. The latter are the only two guaranteed-issue states in which eHealthinsurance sold individual policies during the study period. Massachusetts didn’t make the cut.

We note all this because there’s a far simpler way to tackle the problem of the uninsured than the Massachusetts path. To wit: Let the market operate as it should. Companies like eHealthinsurance have got a great infrastructure up and running and in many states consumers have real choices when it comes to health insurance products. States like New York and New Jersey, meanwhile, might try getting regulators out of the way before following the Bay State in forcing people to buy needlessly expensive coverage.

OK, in truth, we don’t know where Mitt stands on the issue of “guaranteed issue.” BUT, we know where we stand. HCFA was a key participant in 1991 and 1996 in the creation of small and nongroup insurance reform laws the Journal doesn’t like. And because Mitt won’t do it, we will explain where WSJ got it wrong.

We stand behind “guaranteed issue,” the requirement that insurers take all comers, regardless of health status. (By the way, folks seeking individual coverage can’t just buy coverage whenever they want — they have to wait for the annual open enrollment period, which discourages folks who want to wait until they get sick.) We also support “community rating” that says people can’t be charged premiums based on their health status or history. These provisions ensure that sick people can get insurance. In states where insurers can cherry pick customers, individuals with health problems can’t find any coverage at any reasonable rate, and small businesses are priced out of health insurance because one worker gets really sick. It used to happen here in Massachusetts before we did something about it.

Repealing guaranteed issue and other protections allows insurers to collect premiums from you until you get sick and need coverage. Then tough luck to you. The legislature showed wisdom and humanity in finding other ways to bring down premiums. The new health reform law merges the individual and small group markets, expected to bring premiums down by as much as 25% for individuals, while raising them 2% to 3% for small groups. The legislation encourages tighter networks, which may also bring down costs. And, the biggest thing the Legislature did to bring down premiums was to require that everyone get insurance. We did not ask for, or endorse the individual mandate, but it will bring more young and healthy people into the market, improve the risk pool, and bring costs down for everyone.

What can’t work is imposing an individual mandate without guaranteed issue. We can’t require people to get insurance and allow insurers to refuse to sell. The legislature was smart to maintain consumer protections. We need a serious conversation about how to address health care costs. Shifting costs to people who are sick is not a smart answer. (Thanks to HCFA’s crack Melissa Shannon for help with this.)

Watching this morning’s Democratic gubernatorial debate, couldn’t help notice, not a word about health care or the new health reform law. I know Jon Keller invited questions and I failed to respond, better late than never and maybe next time:

1. According the legislative estimates, the new health reform law will begin operating in a deficit by FY2009, a landmark the next governor will reach 18 months into your term. Are you committed to full implementation so everyone in the state has access to quality, affordable coverage within three years?

2. Even business leaders suggest that the $295 assessment on employers who don’t cover their workers is minimal. Do you support raising the assessment to the level endorsed by the House and by 83,000 voters who signed the MassACT ballot petition — 5% of gross payroll for employers with less than 100 workers, and 7% for employers with more than 100 workers?

3. How do you define “affordable”? And do you agree the individual mandate should only be enforced against individuals for whom the purchase of coverage is “affordable?”

4. What will you do to address rising health costs and rising insurance premiums?

Just wondering…

Back in January, when the Maryland Legislature was considering whether to override a gubernatorial veto of the so-called “Wal-Mart bill” — which requires that for-profit employers with 10,000+ workers have to pay at least 8% of gross payroll on health benefits — many were predicting Wal-Mart would financially punish the state for their uppity behavior. Wal-Mart sure doesn’t like the new law, but punish the state? Don’t think so … (from Kaiser Daily briefing)

Wal-Mart President and CEO H. Lee Scott on Wednesday during a conference with reporters in Arkansas said a Maryland law requiring Wal-Mart and other large employers to spend a certain amount on employee health care is “ridiculous,” the Baltimore Sun reports. The law requires employers with more than 10,000 workers in the state to spend at least 8% of their payroll on employee health care or to pay into a fund for the uninsured. Wal-Mart is the only company that will be directly affected by the law. The law will take effect in January 2007. Asked by reporters about the law, Scott said, “The word that comes to my mind is ridiculous, although I probably can’t say that.” Scott said the law would not prevent the company from expanding in Maryland because consumer demand there is strong. “It’s just part of what you deal with,” Scott said, adding, “I think a lot of these things are short-term issues”.

A fine summary of Tuesday’s C-SPAN event in today’s Kaiser Daily Briefing:

State lawmakers on Tuesday at a Washington, D.C., forum sponsored by Families USA discussed the recently a pproved Massachusetts health insurance law, which includes mandates for individuals to have health insurance and for most businesses to offer it to their workers or face penalties. While the individual mandate has been “widely perceived as the key to the political breakthrough … to adopt a plan for virtually universal health care coverage,” the employer requirement is a “key part of the mix,” according to CQ HealthBeat. In signing the legislation, Gov. Mitt Romney (R) vetoed a provision that would assess employers with 11 or more full-time workers $295 annually for each worker without coverage. MA House Speaker Salvatore DiMasi (D) said that lawmakers intend to override the veto. John McDonough, executive director of Health Care for All, said universal coverage will not happen without some form of mandate, adding that the “default” position of advocates of either an individual or employer mandate was to do nothing if their own approach did not prevail. He said DiMasi helped to push the bill through negotiations by proposing both an individual and employer mandate, instead of one or the other. McDonough said critics of the individual mandate supported the plan once the bill included the employer mandate. John Holohan of the Urban Institute, said employer mandates do not work without individual mandates. DiMasi said in order for other states to pass similar laws, they must have both mandates and avoid new taxes. Phil Edmondson of Affordable Care Today said businesses went along with the plan because they were tired of covering the cost of caring for the uninsured through cost-shifting. A webcast of the is available online at kaisernetwork.org.

This was a good event with about 75 folks from media and DC policy groups, with good questions and discussion.

Read between the lines and see a notable point of agreement between Shalala and Thompson (from today’s Kaiser Daily Briefing):

Former HHS Secretaries Donna Shalala and Tommy Thompson on Monday discussed the future of U.S. health care at a conference sponsored by American University’s Center for Congressional and Presidential Studies. Shalala, HHS secretary for 8 years under Pres. Bill Clinton, said she favors expansion of health insurance for all workers through a model similar to that recently adopted in Massachusetts. She said there are a number of ways to increase coverage, including the use of employer or individual mandates or state-run insurance pools. She added that such expansions should occur only if government resources for health coverage are not taken from programs for low-income and disabled residents.

Thompson, HHS secretary under Pres. Bush until 2005, praised the Medicare drug benefit and said he expects more individuals to enroll before the May 15 deadline. Thompson said he supports the Massachusetts law and predicted other states will enact similar laws to address the large number of uninsured U.S. residents. He called for implementation of electronic health records and e-prescribing systems and said the U.S. health system should begin focusing more on preventive care instead of treatment of illnesses. Thompson said he is “absolutely” considering a run for president in 2008, noting that health care will be the leading issue in the election. According to CQ HealthBeat, Shalala was skeptical that health care “would decide the 2008 presidential election”.

Folks on the left and folks on the right kick the heck out of the new Massachusetts law. And folks drawn to the political center of gravity kinda like it. Formula for success or formula for failure? Beats me, but it sure is interesting…

HCFA’s national partner, Community Catalyst, has published a first rate, balanced, and informative overview of the new Massachusetts health reform law. Click here to obtain. Massachusetts Health Reform: What It Does, How It Was Done, Challenges Ahead was written by Catalyst staffer Michael Miller who has been working on this stuff for as long as I have. Great contribution.

We’re hearing it from many quarters. Judy Meredith asked me to address it. Under health reform, employers who cover their workers and have 11 or more full-time equivalent
workers must pay a $295 per worker annual assessment to the state — a charge estimated to accrue $45 million in FY07. Why, many ask, won’t employers stop offering coverage and pay the $295. The individual mandate puts the onus on individuals, giving even more excuse for employer escape.

Reasonable, good question. We don’t think so. Why? Let’s conceptualize three employer types who now provide coverage:

Type A: employers who provide coverage because it’s the right thing to do and they feel responsibility to their workers.

Type B: employers who provide coverage because they can’t attract the caliber of workers they need without offering coverage.

Type C: employers in lower wage sectors where coverage is marginal.

Let’s consider each in turn.

Type A employers provide coverage because they think it’s the right thing. If they drop coverage, their workers will have to find coverage on their own, many may not be able to afford it, and many workers will be angry and upset. They are not likely to drop coverage. By the way, how large is this group? Beats me.

Type B employers provide coverage because they can’t attract the caliber of workers they need if they don’t offer. Under health reform, workers with family incomes over 300 percent of the poverty line will be ineligible for financial help. Employers who drop coverage will leave these valuable workers needing to find coverage on their own. And royally pissed off. Granted, that coverage may be more affordable, but those workers will start looking for other employment opportunities that provide coverage.

Type C employers are in sectors where marginal coverage is the norm — retail, restaurant, construction, other service sector. As we saw in January in the case of Friendly’s Ice Cream — discontinuing full coverage in favor of “mini-medical” benefits — this erosion in coverage has been going on for some time, and these employers do not need the $295 excuse to move in this direction. (And if you hear of employers dropping coverage post-reform, keep in mind that the employer retreat in this category started long ago.)

It’s not the $295 that’s an incentive — it’s the establishment of generous subsidized coverage for workers with incomes under 300%fpl that’s the carrot. As the February 2006 Massachusetts report on employers with 50+ workers using MassHealth or the Uncompensated Care Pool makes clears, workers will gravitate away from marginal coverage and toward better and more affordable forms of subsidized, government-sponsored coverage.

Not that there’s anything wrong with it. (By the way, single payer fans should cheer this.)

Here’s the rub. And here’s the future fight. We need companies in Type C sectors whose workers are drifting toward public coverage to contribute to the cost of that coverage. That’s you — WalMart, McDonald’s, Stop & Shop, Unicco, Shaws/Star Market, Friendly’s. You know who you are.

And the $295? Small potatoes. Not a factor.

Have I got it right or wrong? You tell me.

Sunday’s Globe had a well written op-ed by Dem State Committee Chair Phil Johnston and Blue Cross Foundation Pres. Nancy Turnbull promoting the new health reform statute. Here’s a snippet:

For political liberals like us, who have long embraced employer mandates, putting the onus on the individual has been hard to accept. But like Senator Edward Kennedy and others, we’ve become frustrated by the ideological impasse that has prevented progress on health reform for many decades. So we embrace this bill’s novel approach of combining an individual mandate with subsidies to make coverage affordable, increased employer responsibility, and Medicaid expansions.

Much work lies ahead. But even as we acknowledge those challenges, let us take a minute to recognize what we have achieved. The bill passed by the Legislature expands Medicaid coverage for children. It restores dental care and other benefits for more than a half million Medicaid members. It creates fully subsidized coverage for people at or below poverty, and partial subsidies for the near-poor. It requires individuals with high incomes who have no health insurance to contribute to a system that cares for all of us.

Then there’s the op-ed in today’s Globe by former New England Journal of Medicine editor Marcia Angell:

Like the Medicare prescription drug benefit, the Massachusetts healthcare plan is a complicated morass that might limp along for a while, but will never cover all the people it is meant to cover, and will become increasingly unaffordable. Most likely, it will meet the same fate as the much celebrated 1988 legislation to provide universal coverage in Massachusetts, which shriveled and died with scarcely a whimper.

The only answer is to change the system entirely, so that we can expand coverage while controlling costs. Romney said, ”The old single-payer canard is gone.” No, it isn’t. Sooner or later, that is exactly what we’ll need if we’re really serious about universal healthcare. There’s no other way.

Can they be talking about the same law? Yup. Welcome to the health policy chasm. A couple of comments in response to Dr. Angell. It’s true, the law does not establish a single payer health care system. Guilty, guilty, guilty. If you think that was in the realm of possibility, your legislative sources are better than mine.

And 1988 — yeah, the big part, the $1680 per worker employer mandate was never implemented. Frankly, I recall many single payer advocates trashing that way before it was repealed. Many parts of that law were implemented and stand today — CommonHealth, Healthy Start, Medical Security Plan, among others. But why, Dr. Angell, ignore the 1996 MA health reform law? Could it be because the results spoil your story line? The 1996 law led to a major expansion of MassHealth coverage for hundreds of thousands. In 1995 MA Medicaid had 670,000 enrollees; by 2001, the number reached 995,000. Today, 2006, it’s 1,035,000. Nearly every one of those new enrollees would otherwise be uninsured.

Enjoy the commentary, pro and con. The real verdict on this law won’t be known for 3-5 years after serious implementation work. We’ll be working our butts off to implement it as well as possible. Much better than arguing.

Great piece in today’s NY Times on the chaos that may be caused by the new requirement that all Medicaid enrollees must provide documentation of US citizenship to stay in the program, beginning on July 1, 2006.

It’s not just immigrants who will be hurt by this new rule, included in last year’s abominable federal Deficit Reduction Act.

“‘This provision is misguided and will serve as a barrier to health care for otherwise eligible United States citizens,’ said Gov. Chris Gregoire of Washington, a Democrat.
Ms. Gregoire said the provision would cause hardship for many older African-Americans who never received birth certificates and for homeless people who did not have ready access to family records.

“Hospitals and nursing homes are expressing concern. ‘The new requirement will result in fewer people being eligible for Medicaid or enrolling in the program, and that means more uninsured people,’ said Lynne P. Fagnani, senior vice president of the National Association of Public Hospitals and Health Systems. ‘They still need care, but are more likely to wait until their condition becomes more severe and more costly to treat.’”

Good for Gov. Christine Gregoire. We should encourage other political leaders to speak out against this counter productive requirement.

In the huge volume of writing on the MA health reform law, today’s New York Times editorial gets it as well as anything else I’ve read:

The federal government has done such a miserable job of providing health insurance for the 46 million Americans who lack it that states around the country have been forced to step in with their own plans. The latest and boldest effort was signed into law this week in Massachusetts. It is a carefully crafted plan with elements that could serve as a model for elsewhere, provided Massachusetts finds sufficient funds to make it all work.

The cornerstone of the program is a requirement that everyone have a health insurance policy or pay a financial penalty. States have long required drivers to carry liability insurance, but this is the first time any state has imposed a health insurance mandate.

The move is already raising hackles among libertarians, who consider it an unwarranted government intrusion into decisions that should be personal. But the truth is, very few of the uninsured go entirely without medical care. When they get sick, they typically show up at emergency rooms, where they get very expensive care without paying.

By forcing all residents to assume responsibility for their own health coverage, Massachusetts should largely solve this “free rider” problem and tilt treatments back toward routine and preventive care and away from emergency care.

Of course, requiring people to get coverage doesn’t mean much if they can’t afford to buy it, so Massachusetts has come up with creative measures to make insurance accessible. There will be subsidies for low-income people. Insurers will be allowed to offer cheaper policies with fewer prescribed benefits for young adults. An innovative “connector” organization will serve as a marketplace where people can buy portable insurance with pretax dollars. Small employers can in essence designate the connector as their group health plan, easing their burden. The state’s Medicaid enrollment will also be expanded.

The Massachusetts plan has unusually strong bipartisan support and includes elements drawn from both liberal and conservative playbooks. Although Mitt Romney, the Republican governor, has vetoed several elements of the plan, including a fee on businesses that refuse to participate, he is almost certain to be overridden by the overwhelmingly Democratic legislature.

Lots of details must still be worked out, and there are already concerns that the financial underpinnings of the plan are shaky. But Massachusetts deserves credit for tackling a problem that Washington is failing to address.

Meet the winner of the first Healthy Blog contest — David Massey V (yes, the fifth!). Good genes in that family. Edging out all the smart and sophisticated readers of this blog was David, 16 (”almost 17″), Brookline High junior. He came today to collect his just reward. Apparently, lunch with me was not an attraction — he wants to add to his t-shirt collection. Nonetheless, he stuck around long enough to answer some questions from yours truly.

How did he guess the day and hour of the health reform conference committee filing within 24 hours? “Actually, I intended to guess March 4th but typed the wrong month into my entry.” From the mouths of babes!

What’s his passion besides social justice (he participates in the Brookline social justice program called SAGE)? David is an aspiring film maker and will spend the summer participating in a BU film program. He and a partner are entering a national film competition, and they’re now making a documentary on statutory rape.

He plays varsity volleyball — 2006 team record as of today is 1-2. He’s also a big fan of ulitimate frisbee. He hosts his own blog: rantingsofahighschoolstudent.com but is thinking of giving it up because it doesn’t get much traffic. Help him out, folks…

He’s a world traveler — England, Amsterdam, France, Canada, Kenya, Tanzania. He’s the son of two PhDs, though he’s unimpressed — “Because of that, I learn a lot of useless stuff.” Well, I’m impressed, and grateful for the entry. Thanks, David.

So now … suggestions for Healthy Blog Contest Number Two???