Lessons from Massachusetts Health Care Reform

Looking to a future that breaks the mold built by Massachusetts, we see the possibility of a single payer system that makes our fragmented care whole and redefines our standards.
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As Massachusetts physicians-in-training, we've had a sneak preview of the future of health care in the United States. Across the country health policy-makers are looking to our state as a model. As in Massachusetts, the U.S. Senate and House bills preserve the role of private health insurers, while subsidizing coverage for the poor and near-poor, and imposes an individual mandate requiring everyone else to purchase insurance or pay a fine. Coverage has increased in Massachusetts, with five percent or less of residents now uninsured. The Connector, an Expedia-like marketplace of insurance plans, has offered residents a choice of coverage and is the archetype of a national exchange. When national reform proposals have been criticized for not bending-the-cost curve, proponents have pointed to the cover-now, pay-later strategy in Massachusetts, which is now considering a global-payment cost control proposal to curb unprecedented spending.

If Massachusetts is going to be a model for reform, however, we must consider both the successes and failures of the past three years. It has become painfully obvious both in our studies and clinical practice that coverage does not equal care. Despite boasting the strongest primary care workforce in the country, the newly-insured in Massachusetts report waiting months for appointments. Meanwhile, the Connector has added 4.5 percent overhead to the already crushing administrative costs of our private insurance companies. Premiums have increased drastically since 2006: care in Massachusetts now costs more than anywhere else in the history of the world. Since the Commonwealth has committed to subsidizing low-income residents, premium increases have often come directly from the state's coffers.

Instead of enacting structural reform to rein in costs, the Governor and legislature have chosen to restrict access to care. In May, the legislature eliminated $130 million of health insurance subsidies for 28,000 legal immigrants (mostly green-care holders) who have been here for less than five years. Under pressure from national Democratic Party leaders to highlight Massachusetts' 'successes', the legislature reinstated $40 million to cover this population as a bridge to the next fiscal year. Given the impossibility of ensuring care for this population on a shoestring budget, the state sold these Massachusetts residents' healthcare to an out-of-state, for-profit HMO, CeltiCare. This single-source, anticompetitive contract was signed without the knowledge or consent of these patients.

So far, CeltiCare has restricted access by offering an unprecedented and dangerously limited provider network. CeltiCare has signed up enrollees and then contracted with too few physicians to care for them as a means of suppressing health care utilization and cost. The CeltiCare network excludes most of the safety-net health centers, hospitals, and primary care doctors that previously cared for these patients. CeltiCare has also dramatically increased copayments, amounting to a tax on some of the most vulnerable legal residents of the state.

In our work, we witness the medical consequences of this short-sighted and unjust policy. We see young women in emergency departments for possible ectopic pregnancies - a life threatening diagnosis requiring close monitoring - but now our colleagues cannot provide critical follow-up care in their clinics. So women are sent home and told to look elsewhere for care. Or, when a patient calls in excruciating pain, the only way we can do our jobs is to spend hours searching for barely-permissible loopholes in policy.

To add insult to injury, the Commonwealth has only guaranteed coverage for this cohort of legal residents until June 30, 2010, thus making CeltiCare a bridge to nowhere. What's more, last week the Commonwealth announced that more than one million Medicaid recipients will soon be required to pay higher co-pays and obtain prior approval for critical medications in order to close the state's $307 million Medicaid budget shortfall. As cutting care becomes a proxy for genuine cost-containment, we're left wondering who will next be pushed down this slippery slope.

Health care for all is the moral issue of our generation. We have come of age in a globalizing world. Denying care to foreign-born patients who have played by the rules -- who came here legally to work and pay taxes - is economically, medically, and morally senseless. If universal coverage is our goal, we must recognize that subsidies and individual mandates that exclude many people or leave them with prohibitively high co-payments can never truly be universal.

Architects of reform must not replicate the splintering Massachusetts system, but rather look to the innovative and excellent health systems across Europe and Asia. We must create a federally-funded, privately delivered single payer system, Medicare-for-All as proposed by Sen. Bernie Sanders (I-VT) this week. A single payer system could save $400 billion every year on administration, eliminating the need to "cover-now, pay-later" or place arbitrary restrictions on providers. Having all physicians under one network would eliminate fragmentation of care while empowering patients to have real choices - not just which insurance product to buy, but which doctor to visit.

Looking to a future that breaks the mold built by Massachusetts, we see the possibility of a single payer system that makes our fragmented care whole, that defines a new standard of inclusion, and provides comprehensive, secure, and inalienable rights to all. This is the system in which we, the next generation of America's doctors, aspire to serve our patients.

Iyah Romm
and Sylvia Thompson, M.D. are physicians-in-training in Boston, and national policy leaders in the American Medical Student Association (AMSA).

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