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8. Massachusetts Leads the Way
- Brookings Institution Press
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99 chapter eight Massachusetts Leads the Way It may come as a surprise to some on the left, but it is the Bush Administration that made the state of Massachusetts ’ health-care revolution a reality. Governor Mitt Romney1 Today, the suggestion that a Republican administration had anything to do with Massachusetts health care reform would be more shocking to folks on the right than the left. After President Obama used Massachusetts as a model for national reform, Republican and Tea Party activists started to take a much dimmer view of the scene in Massachusetts. Though George W. Bush did not exactly highlight the fact in his memoir, his administration led the way to reform in Massachusetts by pressuring the state to overhaul its health care system in 2005. Further, the administration explicitly approved key components of the plan that would later be incorporated into Obama’s signature health care legislation. The federal government worked closely with Massachusetts to develop plans for the structure and financing of the overhaul. While Massachusetts helped shape national policy, national health care reform will require some modifications in Massachusetts. The details of the Massachusetts reform— including the role of the federal government and the state’s struggles with rulemaking and implementation—provide lessons for implementing national reform. Passed in 2006, the Massachusetts health care reform was a remarkable success. Thanks to so-called “Romney Care,” 98 percent of residents had insurance coverage by 2008, and those gains held steady through the 08-2483-4 chap8.indd 99 6/25/13 5:32 PM 100 / massachusetts leads the way economic downturn.2 The plan provided greater access to health care services , particularly for low-income residents.3 Fewer people reported going without necessary care, and there was increased use of prescription drugs and preventive health care services.4 Major progress was also made in reducing racial and ethnic disparities in access to health care services.5 However, the plan focused largely on access and did not directly address persistently rising health care costs.6 Reform did pressure the political system to explore cost containment and health care delivery system reforms—steps that will be essential to maintaining near universal coverage. Massachusetts reform was based on the principle of shared responsibility . It asked individuals, government, and employers to do their share, and it was unique in that it included an individual mandate requiring anyone who could afford health insurance to purchase it. It also created the Massachusetts Health Care Connector, a forerunner of the health care exchanges required in every state by national reform. After hard-fought negotiations, the Massachusetts reforms ended up being bipartisan, passing both the state house of representatives (155-2) and the senate (37-0), in sharp contrast to the Patient Protection and Affordable Care Act (ACA), which in the end passed entirely along partisan lines and was later repealed by the Republicancontrolled House of Representatives. Medicaid and Federal Waivers Massachusetts reform built on a long history of innovative expansions of health care coverage. It grew from the MassHealth program, the state’s Medicaid program, which was created through a waiver from the federal government .7 Some background on Medicaid and the state’s waiver is essential to understanding the 2006 reforms. Medicaid is a health insurance program for qualified low-income residents that is run by individual states under federal guidelines. The program is a complex intergovernmental morass, but it provides essential services to many, but not all, of the most vulnerable individuals .8 The largest group of recipients is poor mothers and children; the program also helps many low-income seniors and people with disabilities. Many other groups are covered at state option. There is an old adage: “If you have seen one Medicaid program . . . you have seen one Medicaid program.” A Medicaid recipient in Minnesota may not be eligible for coverage in Mississippi, or the recipient might be eligible for a very different set of benefits. To keep it all straight, states submit detailed eligibility and coverage plans, which are approved by federal officials. On the basis of those plans, states receive partial federal matching funds, on a 08-2483-4 chap8.indd 100 6/25/13 5:32 PM [3.143.229.82] Project MUSE (2024-04-17 21:12 GMT) massachusetts leads the way / 101 sliding scale of between 50 and 76 percent, with less affluent states getting a more generous reimbursement. So when a state like Massachusetts (with a 50 percent match) spends a dollar, the federal...