WASHINGTON - Key players in the debate over how to provide healthcare coverage for the nation's 47 million uninsured say they view Massachusetts' landmark 2006 law as an important model for what Washington could do and how to get it done.
Massachusetts achieved near-universal coverage by investing heavily in patching the holes in the existing system, where most people get coverage through work - something economist Jonathan Gruber of MIT calls "incremental universalism." This centrist approach rejects both the liberal vision of a Canadian-style Medicare-for-all system and the conservative preference to move to a deregulated market where people buy policies on their own with the help of tax credits.
"The architecture of the Massachusetts plan is very similar to the architecture of what everyone is talking about, which is essentially building on the existing system and not throwing it out," said Drew Altman, president of the Kaiser Family Foundation, a nonpartisan health policy group based in Menlo Park, Cal.
With a new administration and Congress gearing up to push a major initiative to expand insurance access for the first time since the Clinton administration's spectacular failure in 1994, Washington policymakers are eager to avoid making the same political mistakes. Massachusetts leaders made sure that people who liked their coverage could keep it, and they built consensus among a web of healthcare interests to create a new safety net for the uninsured.
"What Massachusetts demonstrates is, it can be done," said Helen Darling, president of the National Business Group on Health, which represents the views of large corporations on health care. "It's really important because people have talked about what we might do for years and years and years. This shows it can work, and for the most part, it can be highly functional."
Senator Edward M. Kennedy, a leader on health care in the Senate who also helped create the state law, cited new figures released yesterday showing that 97.4 percent of Massachusetts residents now have insurance, compared with 90 percent when the law was passed in 2006.
"To those who say these challenges can't be met, I say, 'Look at Massachusetts,' " he said in a statement.
Some of the people who shaped the Massachusetts law are now contributing to the national debate. Kennedy has hired as a senior adviser John McDonough, the former executive director of the Boston-based advocacy group Health Care For All, an influential advocate for the Massachusetts law during its creation and passage. Kennedy has consulted with Jon Kingsdale, executive director of the Commonwealth Health Insurance Connector Authority, the entity responsible for implementing the Massachusetts law and for helping those without coverage shop for insurance. Gruber, the MIT economist, advised former governor Mitt Romney and the Legislature on developing the Massachusetts plan and now serves on the Connector Authority board and works informally with Senate staff and the Obama transition team.
"From both policy and political perspectives, it is impossible to underestimate the positive influence of Massachusetts reform on the prospects for national health reform in 2009," Kennedy said in a statement.
Both President-elect Barack Obama, in the healthcare plan he released during the campaign, and Senate Finance Committee Chairman Max Baucus, in his 89-page white paper, have endorsed a Massachusetts-style "incremental universalism" approach, as well as some of the fundamental steps the Bay State took to fill in the cracks in the system: Expand public programs like Medicaid to insure more children and more poor people. Provide subsidies for middle-class people who cannot buy affordable insurance through work. And set up a kind of "Travelocity of health insurance," as one policy adviser called it, to help people easily compare and purchase affordable plans - as Massachusetts does through its Commonwealth Health Insurance Connector Authority.
They also support requiring most employers to offer insurance, with help for small businesses, even though business lobbies have long resisted such a mandate.
Massachusetts also required almost all individuals to buy insurance. Obama in his campaign said insurance should only be required for children, not adults, but the concept of an "individual mandate" for insurance may be gaining steam: Baucus and Tom Daschle, Obama's pick for secretary of Health and Human Services, have endorsed the idea. And last month, America's Health Insurance Plans, the nation's largest insurance lobby, promised to stop denying coverage to those who are sick - another key component of the Massachusetts plan and a top priority for Obama and Congressional leaders - as long as the law required everyone to buy health insurance.
Congressman Frank Pallone, Jr. a Democrat from New Jersey and the chairman of the health subcommittee of the House Energy and Commerce Committee - which has yet to weigh in with its own plan - said both those ideas are critically important.
"I think an individual mandate is important because it just means you're going to have everybody covered in some fashion," he said, adding that a prohibition on discriminating against sick people is also "crucial."
US Senator Judd Gregg, the ranking Republican on the Senate Budget Committee, however, said the Massachusetts plan may have some valuable ideas but the jury is still out on its cost-effectiveness. He said he is wary of a forcing people into buying more expensive insurance than they need.
Congress is unlikely to adopt an exact replica of the Massachusetts law for the nation, specialists say. The state started out with fewer uninsured people than the nation as a whole, and more residents already had very generous health insurance coverage, so requiring all Americans to have the same comprehensive insurance as Massachusetts residents could be expensive and politically treacherous.
Massachusetts also had pools of federal money available for investing in health care.
"Every state is different," said Baucus in a statement. He said he studied the Massachusetts plan "very closely" in putting together his proposal but that there are limits to its transferability.
A national health insurance plan would also probably include elements the Massachusetts law lacks, like more muscular efforts to reduce medical costs and improve quality - components that leaders in both parties agree are extremely important and which some specialists say are best addressed on national scale. It could also include a public Medicare-style insurance option for those who cannot get coverage through work. And Washington policymakers are considering reducing tax breaks for those who buy insurance through work in order to help subsidize coverage for those who cannot.