Failure of Massachusetts health care reform?

Last week, Physicians for a National Health Plan and Public Citizen, two advocacy groups, released “Massachusetts’ Plan: A Failed Model for Health Care Reform.”
The authors state that Massachusetts’ reforms
• Have not reduced uninsurance as much as as advertised
• Have not addressed the soaring cost of health care
• Expose those of modest means to large copayments and deductibles
• Reduce the subsidies for “safety net” providers, which threatens access to the most vulnerable
• Increase waste in the system, by using commercial (though nonprofit) health plans and by imposing a fee to support the work of the Connector, the agency that administers the insurance exchange at the heart of health care reform here.
Jon Kingsdale, the executive director of the Commonwealth Health Insurance Connector Authority Board, disputes the statistics on cost increases and the number of uninsured.

This report correctly reports many of the challenges faced by health care reform here in Massachusetts. But let’s be sure not to blame the health care reform for problems beyond its mission, and let’s not forget about the real accomplishments.

Some big accomplishments:
• The Connector merged the individual and small group markets, allowing for better pooling and much more affordable policies for many Massachusetts residents.
• No one argues that the number of uninsured has gone down, and the PNHP document points out that the amount of free care delivered went down by over a third (although the authors complain that this decline should have been 75%)

Some problems beyond the scope of Massachusetts health care reform
• The number of employees in the private workplace has declined due to the economic maelstrom around us. In Massachusetts, we’ve learned before that economic malaise can torpedo efforts to expand health insurance.
• Reductions to safety net providers were mandated by the Bush administration, who threatened to cut off $350 million in federal funds. This can and should be revisited as part of the federal stimulus plans going forward.
• The health care reform authors explicitly avoided addressing the cost issue in the initial legislation. They recognized health care inflation would need to be addressed, and felt this was substantially more difficult than expanding coverage, and should be deferred until we provided coverage to more residents.

We all know that health care reform will ultimately be unsustainable if we don’t control costs. The costs we have to control are in the delivery system – and sharply limiting administrative costs alone will not fund large expansions in access. However, if 1/3 of all health care costs are unnecessary (Fisher, Annals, 2003), it will take a long time to unwind these costs. Perhaps Boston will need one or two fewer teaching hospitals, with dozens of thousands of job losses. It might not be wise to try to eliminate all those extra costs right this moment, when so many other portions of the economy are shrinking so violently.