"Disappointing but Fair": The Connector's Challenge

All societies, no matter how wealthy, must set limits on health care. Rapid advances in technology combined with an aging population make limits unavoidable. The fact that we in the United States have not agreed on an approach to setting limits and have lacked the political will to come up with one is a central impediment to the comprehensive reform we so obviously need.

In our 2002 book Setting Limits Fairly, Norman Daniels and I asked how societies can meet the health needs of the population fairly under conditions of resource constraint.¹ We concluded that given the absence of widely shared principles that would simply tell us how limited resources should be allocated, societies must rely on a fair decision-making process. We called this process "accountability for reasonableness," and we specified four conditions under which a limit-setting process stood a chance of appearing legitimate and fair. First, decisions about limits and their rationales must be publicly accessible. Second, the rationales for limits must be based on evidence, reasons, and principles that explain how the policy seeks to meet the health needs of individuals and a defined population under resource constraints. Third, there must be opportunities for appeals and for the revision of policies in light of experience. Finally, there must be assurance that the conditions for accountability will be met.

The Massachusetts plan for health care reform is the most innovative experiment in setting limits since the Oregon Health Plan in the late 1980s. From the perspective of advancing accountability for reasonableness in the U.S. health system, it is also very promising.

Playing new music on old instruments.

The Massachusetts plan uses the same "instruments" as the dysfunctional U.S. health care system, but it seeks to play a new melody—the music of social justice. Individuals will be required to purchase insurance from a set of "affordable" products that offer "good value" and "high quality." Employers who retain eleven or more employees and do not provide health insurance will be required to make a "fair share" contribution to the system. Health plans will be asked to create less costly products, and plans participating in Commonwealth Care (the new subsidized insurance program) will be given enrollment targets to achieve. The state government's goal is nearly universal coverage.

Writing new music does not in itself bring about a successful concert. But thus far Massachusetts appears to have orchestrated broader deliberations about access, accountability, and affordability than the United States has seen since the Oregon Health Plan. By insisting that health care reform requires new actions by all constituents, Massachusetts has taken a necessary first step in what could ultimately lead to far-reaching changes.

Making tough decisions.

Not surprisingly for a plan created by bipartisan compromise, the legislation recurrently evades the areas of greatest conflict by burying them in undefined terms: "reasonable" (eighteen mentions), "fair" (thirteen mentions), "affordable" (seven mentions), "high quality" (two mentions), and "good value" (one mention). The law provides a broad framework. The process it sets in motion has to give meaning to the crucial elements.

The thorny job of deciding what constitutes high-quality health care with fair limits and at an affordable price is assigned to the newly created Commonwealth Health Insurance Connector Authority. From the perspective of Setting Limits Fairly, the Connector is accountable for the reasonableness of the new program. The law defines the Connector as "an independent public entity" charged with performing "an essential public function." Four of the eleven members of its board are state officials. Three more with expertise in finance and business are appointed by the governor (currently a Republican). The Attorney General (currently a Democrat) appoints a further three with ties to the consumer community and labor unions. (Oddly, the law specifies an eleven-member board but identifies only ten appointees.) The Connector has authority to make independent decisions, but must report to the governor and the legislature at least annually.

The Connector is a promising construct for addressing deeply conflicted questions about social and individual responsibility in health care. Like the Federal Reserve, it is independent, which might allow it...