I found the take of the New York Times on the experience with the Massachusetts health care reform plan interesting. As you might expect the NYT is completely on board with the idea of universal coverage and their description of Massachusetts’s experience is quite rosy:
The number of uninsured has dropped — Massachusetts now has the lowest rate in the nation — and so have the number of those who turn to costly emergency rooms for routine care. And while the state has had to seek additional sources of revenue — mainly because of the program’s popularity — the gains in the first 21 months suggest that the plan could become a model for universal health coverage for other states or the nation.
[…]
More than 40 percent of the newly insured purchased private commercial policies without any government subsidies, defying dire predictions that employers would drop their plans and a horde of individuals would drop private policies. What seems to be happening instead is that workers who previously shunned their employers’ plans have decided to sign up now that insurance is required.
The big expansion in coverage has yielded a commensurate drop in the number of “free riders,†those who use hospital emergency rooms and community health centers for routine care that they don’t pay for. The cost of that uncompensated care dropped from $166 million in the first quarter of fiscal 2007 to $98 million in the first quarter of 2008.
For a somewhat more balance description of the plan you might want to take a look at this article from the New England Journal of Medicine:
After 2 years, the good news is that the new programs have ramped up rapidly, the number of people without health insurance has been substantially reduced, and overall public and political support remains broad. Early data suggest that access to care has improved, especially among low-income adults; there have also been “reductions in out-of-pocket health care spending, problems paying medical bills, and medical debt.”2 As of May 2008, about 350,000 residents — 5.5% of the state’s population — were newly insured (see figure). About half of them are enrolled in Commonwealth Care, a subsidized insurance program for adults who have no access to employer-sponsored insurance, Medicare, Medicaid, or veterans’ or student insurance programs and who earn no more than 300% of the federal poverty guidelines. About a third have purchased private insurance or gained employer-sponsored coverage, and the rest have enrolled in Medicaid. About 72% of the approximately 25,000 people with new individual policies have purchased them through Commonwealth Choice, an unsubsidized offering of private health plans approved by the Commonwealth Health Insurance Connector Authority, which administers many aspects of the reforms. In addition, the individual and small-group insurance markets have been merged, markedly reducing the cost of individual premiums.
Not all the news is good, however. Perhaps 5% of the state’s population — the exact figure is a matter of conjecture and may be higher — is still uninsured, the financial burden of the reforms is increasing, and the challenges of sustaining the subsidized program have been exacerbated by the economic downturn. The features of plans that decrease the cost of premiums also increase out-of-pocket costs for those who obtain care. Although adults reported lower levels of health care needs that remained unmet because of cost in the fall of 2007 than in the previous year, those with low incomes reported increased difficulty in getting appointments or in finding a doctor or other provider who would see them.2 And the state ultimately decided that not all residents must actually carry health insurance, as the legislation originally intended: exemptions are available for adults who make too much money to enroll in the subsidized insurance program but are deemed unable to afford policies in the private market; others can be exempted on religious grounds or when unusual financial circumstances arise. If more residents were eligible for subsidized insurance, fewer would qualify for hardship exemptions, but such an approach would further increase the cost of the new programs. Already, enrollment in Commonwealth Care is growing faster than was projected. Annual state spending would be $1.08 billion for fiscal year 2009 if 255,000 residents are enrolled, an increase of about 80,000 enrollees from the current number.3 If 225,000 residents enroll, as an earlier estimate suggested, spending would be $869.4 million. By comparison, spending for Commonwealth Care was $132.9 million in fiscal year 2007 and is projected to be $647.4 million in fiscal year 2008. Moreover, as compared with the national average, the per-capita cost of medical care in Massachusetts is high.
I urge you to read both the NYT editorial and the NEJM article in their entirety.
There’s an interesting aspect of the NYT editorial: they’ve abandoned the claim that universal coverage will decrease costs, a view dearly beloved to those pushing the adverse selection theory of high health care costs, in favor of noting the publish health benefits of universal coverage.
Frankly, I doubt that we can make a judgment on the Massachusetts plan yet. There’s no question that through some combination of mandates and subsidies we can extend coverage to practically everybody. The question is whether political support can be maintained for such plans in the absence of serious cost control. Additionally, as the NEJM article on the Massachusetts plan suggests, universal coverage doesn’t automatically increase the amount of health care so that everybody can actually get the health care that he or she needs.
My view remains that the real problem with our health care system is that the costs are too high, the only practical way to address high costs is a dramatic change in the way health care is delivered to increase the supply of health care, and that a universal system can’t survive here without marked immigration reform.
