Is legislating universal health coverage enough?

Massachusetts first state to guarantee coverage

With the implementation of health care reform passed in 2006, Massachusetts became the first state in the country to enact a law guaranteeing health insurance coverage to all its citizens. In the 12 months leading up to the July 1, 2007, implementation of the law, more than 155,000 Massachusetts residents had enrolled with health insurance providers — progress that state health insurance official Jon Kingsdale, PhD, hails as "a big step in the long march toward near-universal health coverage."

While health care providers say it's too early to tell whether the measure will be of benefit in delivery of care, ethicists say one positive feature is the elimination of many preexisting conditions that previously were used to disqualify some applicants.

The Massachusetts health insurance plan is being closely watched by other states considering universal health coverage. Features of the plan include:

  • Free health insurance to residents with incomes slightly above or below the poverty level;
  • Insurance on a sliding-scale basis for low- and moderate-income residents who have no source of coverage;
  • The Connector, a new source for coverage with different choices of affordable health insurance plans for individuals and their families;
  • The requirement that adults who do not have health insurance get coverage if affordable coverage is available. Adults who do not qualify for free or subsidized health insurance or a waiver must pay a penalty.

All employers — except for very small businesses — are now required to offer their employees health insurance and pay a fair share of the cost, or else pay a penalty. Massachusetts is only the second state, after Hawaii, to mandate employer-funded health insurance.

Fines for non-compliance increase dramatically as time passes, which officials hope will spur employers and individuals to act quickly. There are no criminal penalties for not purchasing insurance.

"The new plans we offer will be more affordable for tens of thousands of Massachusetts workers who might otherwise remain uninsured because they are not able to purchase insurance directly through their employer," says Kingsdale, director of the Massachusetts Health Insurance Connector Authority. "The fact that we are on track to surpass our projections is indicative of the need for this program, the high level of benefits it offers, strong outreach, and collaboration with many partners who have helped to simplify the enrollment process."

However, some health care organizations remain unconvinced. They view the plan as uncomfortably similar to one proposed in the 1980s that collapsed within two years due to funding issues.

"The requirement that most of the uninsured purchase coverage will either require them to pay money they don't have, or buy nearly worthless, stripped-down policies that represent coverage in name only," says Steffie Woolhandler, MD, MPH, co-founder of the Chicago-based Physicians for a National Health Program and a primary care physician in Cambridge, MA.

Additionally, says Woolhandler, "the legislation will do nothing to contain the skyrocketing costs of health care in Massachusetts, already the highest in the world."

[For more information, visit the Massachusetts Health Insurance Connector Authority on-line at www.mass.gov/connector. Contact the Physicians for a National Health Program at (312) 782-6006.]