Universal Health care: Can it Work here?

Shared responsibility is key to Bay State's compromise


WASHINGTON -- Massachusetts' groundbreaking legislation to make health insurance universally available may not work as a direct model for other states, but it does demonstrate that a melding of conservative and "progressive" ideas can bring political consensus, according to key players involved in designing the plan.

The Bay State has some big pluses - namely fewer uninsured than other states and an available source of funding. But the law, which takes effect next year, could usher in broader effort by the states to tackle a problem that has evaded a national solution.

"States should look at this less as a policy blueprint and more as a political blueprint," said John E. McDonough, executive director of a Massachusetts advocacy group called Health Care For All.

The Massachusetts plan, passed last week, penalizes both employers who don't offer insurance coverage and individuals who can afford insurance but don't buy it. For those who can't afford insurance, it would provide free or subsidized coverage. And it would set up a quasi-public clearinghouse to help small employers and individuals find policies.

"If you're going to ask individuals to do something, you'd better ask employers," said Salvatore F. DiMasi, the Democratic speaker of the Massachusetts House of Representatives. DiMasi was a key engineer of the compromise legislation that won bipartisan - and nearly unanimous - legislative support. DiMasi, McDonough and others spoke at a panel discussion here this week sponsored by Families USA, a national consumer group.

It's too early to tell whether the Massachusetts plan is the start of a new consensus on how to cover the uninsured or an anomaly, said Alan Weil, executive director of the National Academy for State Health Policy, a nonpartisan group that serves as a resource for states.

What is clear, Weil said, is that the passage of the law "has sparked renewed debate about what states can or cannot do."

In Maryland, two groups that want health reform - and that are usually in contention with each other - said they see many elements of their own proposals in the Massachusetts law.

Both Glenn E. Schneider, executive director of Maryland Citizens Health Initiative, and Robert O.C. Worcester, president of Maryland Business for Responsive Government, said they thought the Massachusetts law might serve as a guide for Maryland reform.

Schneider said his group would be meeting with its technical advisory committee to "kick the tires of the Massachusetts plan," and see if its Maryland plan should be tweaked. However, he said, key details of the Massachusetts program remain to be worked out, so "it lacks guts and flesh to evaluate it fully."

Worcester described the Massachusetts bill as a modified version of a plan developed for Maryland by his group and the Heritage Foundation. He said the Massachusetts compromise - worked out by a Republican governor and heavily Democratic legislature - encouraged him to think some form of health reform might be politically feasible in Maryland. "I wouldn't have been knocking my head against the wall all these years if I didn't think it was possible," he said.

So far, at least, middle ground has been elusive in Maryland - and in most other states.

For several years, Schneider's group has backed a plan that included "play-or-pay" requirements for employers and individuals, meaning those who don't spring for insurance have to pay a penalty to the state.

Worcester's group has staunchly opposed a mandate on employers, battling against both the overall Citizens' Initiative plan, which has died annually in the General Assembly, and a limited version for large employers, the so-called "Wal-Mart bill," enacted this year over the veto of Gov. Robert L. Ehrlich Jr.

In Massachusetts, the key to building consensus for reform was to draw ideas from "all parts of the political spectrum," McDonough said. Traditionally, he said, Democrats and progressives have sought to require employers to provide coverage, but business opposition has doomed those efforts. Republicans and conservatives, he said, have stressed individual responsibility.

In other states, he said, the deadlock has resulted in doing neither; Massachusetts was the first to say, "Let's do both."

Philip J. Edmundson, chief executive officer of William Gallagher Associates, a Boston-based insurance brokerage, said that while business people instinctively don't like imposed requirements, some businesses that provide insurance supported the plan because they realized they were paying directly and indirectly "for their employees and everyone else's."

Also, he said, negotiators eventually settled on a flat annual $295 per worker penalty for businesses that don't offer coverage, down from as much as 7 percent of payroll.

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