Bipartisan Health Reform?

This issue's special set of essays on the Massachusetts' health plan reform effort does not satisfy the informal call for papers, issued in this space in the last issue, for essays and articles on the questions of social justice and health care. But it's a step in that direction.

The essays continue the sometimes combative but multiperspectival engagement that characterized the reform itself. In the lead essay, Jonathan Gruber, a health economist at the Massachusetts Institute of Technology who advised the state on the reform, lays out the essence of the plan, how a Republican governor and a largely Democratic legislature hammered it out, and what the remaining issues are in implementing it. The five commentaries that follow praise and criticize the effort from various sides.

Inevitably, one issue debated in these essays is the plan's rather complex strategy for reducing the number of uninsured. The plan combines a mandate that all Massachusetts citizens purchase insurance, subsidies for some with low incomes, and a restructuring of the state's insurance market. Steffie Woolhandler and David Himmelstein, cofounders of Physicians for a National Health Program, argue that the reform does not include enough funding to provide the promised subsidies, that many of those who are not subsidized will not find affordable insurance, and that the insurance will be too stripped down to be adequate anyway. A single-payer plan would have been better, they argue, because it would better solve the affordability problem.

From the other end of the political spectrum, Michael Tanner, director of health and welfare studies at the Cato Institute, laments the reform's use of government mandates and controls. The mandate that individuals purchase health insurance will not work, he asserts, and the constraints on the market will have unintended consequences that push the goal of universal coverage over further out of reach. It would be better, he argues, not to put so much emphasis on expanding coverage, to focus instead on making the insurance better, and to rely on market mechanisms to achieve this end.

Another exchange in these essays is over its unfinished work. Susan Dorr Goold and Nancy Baum, who work on health policy issues at the University of Michigan, expand on the problem of what constitutes "affordability" and whether the Massachusetts effort provides it. Even a family beyond the reach of the plan's subsidies may not find anything really "affordable," they maintain. On the other hand, James Sabin, coauthor with Norman Daniels of Setting Limits Fairly: Can We Learn to Share Medical Resources? applauds the plan for establishing a promising framework for working through such problems. He affirms that it leaves much to be resolved, but he finds in it appropriate mechanisms for making these decisions "in an open, accountable manner."

In the concluding essay, Daniel Callahan, of The Hastings Center, sets aside the details and comments on how the plan might contribute to national health care reform. Gruber began the essays with an oft-repeated joke about the grim view most health policy experts take of the chances for achieving universal coverage in the United States. Callahan closes with "an un-confident prediction" that things may finally be coming together to make such reform possible.

Thanks go to Garth Sheldon-Coulson, a senior at Swarthmore College who was an intern at the Center this past summer, for undertaking much of the work necessary to bring these essays together.