Q & A: Promise and Pitfalls of Mass. Health Initiative

Lawmakers in Massachusetts earlier this week enacted a sweeping healthcare bill that aims to insure almost every citizen over the next three years. But unlike with previous proposed health care initiatives, the state would not be solely footing the bill.

Massachusetts is trying a different way to get universal coverage. It will provide some subsidies, but for the most part, individuals will be required to buy health insurance if their employers do not.

Stuart Altman spoke with NPR about the bill, which is now before Republican Gov. Mitt Romney. Altman is a health economist who is dean of the Heller School of Social Policy at Brandeis University. He has been involved in health care reform efforts since the 1970s. In 1997, President Bill Clinton appointed him to the National Bipartisan Commission on the Future of Medicare.

Q: Why is this happening now in Massachusetts?

We're sort of where we were in the late 1980s, where businesses are increasingly frustrated by the high cost of their insurance. The numbers of uninsured continues to grow. The providers – the hospitals and the doctors – are being asked to provide more care for people that can't pay.

Q: Republican Governor Mitt Romney in a sense is following in the footsteps of his Democratic predecessor, Michael Dukakis, who got a short-lived universal health care bill enacted in 1988. So is Mitt Romney the Mike Dukakis of his day? And how much credit does he deserve for getting Massachusetts to this point?

Mitt Romney deserves some credit for this. To be honest with you, I wasn't completely convinced that he was serious about it when he did it. And I just thought he was just throwing it out and would just leave it out there. But not only did he not do that, but the legislature, which is controlled by the Democrats, took it seriously and each, the Senate and the House, came up with their own plans and they've been jockeying back and forth now for the better part of six months to try to come up with a compromise that everybody can support. And I think they did it.

Q: Are there pitfalls for Romney, as a Republican, in supporting a universal health care system?

I think there are significant elements in the Republican Party that would like to see an issue like this just go away. But to be fair, I do believe that there are a significant proportion of the Republicans that recognize that we need to do something. Most Americans believe that every American should have some form of coverage.

Q: What are some of the more controversial aspects of this bill?

How to define "affordable" is going to be a debate. There are going to be people on both sides of the aisle who are going to say “How can you ask someone who's making $25,000 to have a $5,000 or $2,000 deductible?”

Q: So do you think "affordable" health insurance will translate into "worthless?"

I'm not one of those people who believes that a reduced-benefit package is worthless. We can all come up with worst-case scenarios. But to me the worst-case scenario is that within five years we could have 60 million Americans with no health insurance whatsoever. And unfortunately, I've been part of these wars now since the early 1970s, and I've seen too many times where the so-called "best" destroys the decent or the good.

Q: What would a $200-$400 policy buy you?

Exactly what it buys will depend upon how the policy is put together. I mean, you could have a limited number of hospital days. You could exclude certain kind of benefits that people traditionally think of. There could be limits on prescription drug coverage. So you could either go down in the number of benefits or you could go down on the costs of the copayment and deductible. And probably you'd have to go down on both sides if you wanted to keep the price that low.

Q: How far will the provisions that allow people to use pre-tax dollars to buy insurance go toward bringing down the cost of premiums?

I don't see these provisions significantly reducing premiums. I think in order to reduce premiums you have to either limit the benefits or increase the coinsurance and deductibles. That's where the real money is.

Q: Is there enough of a state subsidy to make these plans affordable to low-income families?

I'm not sure there is. I think at the end of the day, as we define what's affordable, it may turn out that the state subsidies are inadequate. At this point I can't tell you whether they are or they're not.

Q: How does the state plan on generating enough interest among the insurance companies to develop these new, low-cost plans?

I'm not sure that you're going to have a lot of insurance companies jumping for joy. I do believe that the state will have to look hard for incentives. If they ask too much and provide too little for the insurance companies, I don't think they will play.

Q: Do you think the Massachusetts law disturbs the universe of health policy initiatives?

It is my kind of a bill in the sense that it's incremental. It does build on our crazy-quilt system. I call it a uniquely American system; it builds on the pieces and makes them stronger. I think at the end of the day, though, we need to get the federal government into this business. I am not a believer that we can create universal health care state by state.

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