WASHINGTON — The warning resounded through the 2012 presidential campaign. Massachusetts’ groundbreaking health reform, Republican nominee Mitt Romney said, would never work for the country as a whole.
Democrats widely dismissed Romney’s comments as politically opportunistic, an effort to distance himself from the plan he backed as governor. Now, given the epic scale of problems that have bedeviled the rollout of President Obama’s plan, some state legislators, insurance and hospital executives, and others around the country are returning to Romney’s refrain.
Was the Massachusetts plan, in hindsight, really the best blueprint for the nation?
“They should have allowed more flexibility on a state-by-state basis,” said Massachusetts state Senator Richard Moore, a Democrat and key architect of the state’s health reform law.
While the Massachusetts model may work for some states, Moore said, imposing a uniform standard across the country was folly because it did not take into account the unique dynamics of local insurance markets, regional variation in health care delivery, and even the political and social culture of other states.
Obama and other Democrats in 2009 and 2010, when they were drafting their law, Moore added, would have been better served to use the Massachusetts model as a flexible framework for states to adopt over time, rather than a blueprint for a mandatory national plan.
“Not every state has the same set of circumstances that we inherited to our benefit,” said Moore. He said the federal government could have set broad goals such as universal coverage, sliding scale subsidies, and minimum coverage standards that allow states to use a mix of federal and private dollars to expand. There should still be an individual mandate, he added, but only if coverage is affordable.
Andrew Dreyfus, chief executive of Blue Cross Blue Shield of Massachusetts and another supporter of the Massachusetts and national health care plans, said the question has popped up in meetings he has attended around the country, with increasing frequency.
“People keep peppering me with the question about Massachusetts wherever I go outside the state,” he said. “Given what’s going on in Washington, was the Massachusetts model a good one to use?”
Dreyfus said he believes the answer is yes — the Massachusetts model is still a viable option for the country in the long term — but that “it isn’t right for every state now.”
“In some ways, we may see the Affordable Care Act evolve into a more state-based system,” Dreyfus said. “Some states may look very much like Massachusetts, and some may look a lot different or may take a lot longer period to get to where we got.”
These are the sorts of assessments that were thrust to the forefront this week at an annual meeting of the National Conference of State Legislatures in Washington, where the organization’s health reform task force examined how states are responding to the mass public confusion caused by the law’s botched rollout. “It’s the most daunting challenge I’ve faced in 20 years as an elected official,” said Alabama state Representative Greg Wren, the task force’s Republican cochairman. “The feds passed something the states did not have involvement with, and yet we’re being forced to implement a patchwork of federal ideas, and now we’re being asked to help in saving the health law.”
Like Massachusetts, the federal plan mandates that most Americans buy insurance in 2014 or face a tax penalty; requires insurance plans to be sold through an online marketplace where consumers could make comparisons; provides insurance subsidies for low-income individuals; and fines larger companies that don’t offer insurance to their employees.
Already, the unified sweep of the federal law has splintered considerably. Following a Supreme Court ruling in 2012 that made Medicaid expansion optional for states, 25 of them, including Maine and New Hampshire, have opted out of that portion of the law.
And because of widespread Republican resistance to the law from governors and state legislators, 36 states, including Maine and New Hampshire, have not launched their own online insurance portals, leaving it to the federal government to oversee those marketplaces. Consumers living in states that set up websites have had a much smoother shopping experience overall.
As Obama attempts to weather wave after wave of controversy, he continues to move back deadlines and give states increasing flexibility to adapt.
For example, seeking to recover politically from his broken promise that all people could keep their health care plans, Obama gave individual states the option of allowing noncompliant plans to remain in place for another year. About two dozen states, including many that have embraced health reform such as Massachusetts, Washington, and New York, have said no. The other half, including Florida, New Hampshire, and Maine, will allow the renewals of such plans.
“There are now four or five variations of what state markets could look like,” said Dreyfus, whose company, Blue Cross Blue Shield of Massachusetts, was the only individual insurance plan in the country that filed a friend of the court brief backing the Affordable Care Act during the Supreme Court case.
Several Democrats in Congress, including those who have sponsored bills to amend the federal law, say they are not ready to dismiss the Massachusetts blueprint despite their misgivings about the law’s implementation. “We looked at the Massachusetts-type model because it’s based on a competitive, Republican-style market-based plan,” said Representative Diana DeGette, a Colorado Democrat and member of the Energy and Commerce Committee that drafted the House version of the health bill.
An aide to Senator Mary Landrieu, a Louisiana Democrat who is pushing a bill to allow consumers to keep their noncompliant insurance plans indefinitely, said the problems with the rollout are inexcusable but in states willing to embrace the health overhaul, the Massachusetts plan is working.
Senator Edward Markey of Massachusetts, who was a senior member of the committee that drafted the House version of the health bill, said it is the federal government’s responsibility to ensure a right to health care rather than leaving it up to each state to create a patchwork of policies.
“Every American should have access to quality, affordable health care just as Medicare and Social Security provide vital benefits that millions of Americans depend on, regardless of the state in which they live,” Markey said in a prepared statement. Still, it is difficult for Republicans not to gloat.
“I do think that one of the fundamental problems we’re seeing now is that the Obama administration was attempting to federalize something that ultimately cannot be federalized,” said Lanhee Chen, Romney’s policy director during the 2012 campaign. “Governor Romney’s criticism turns out to have been quite accurate.”
What worked in Massachusetts will probably not work in all 50 states, each with its own political dynamics, he said — not to mention that insurance has always been regulated at the state level. “If you try to impose a one-size-fits-all framework, you’re going to run into some difficulties, and I think the administration is learning that the hard way,” Chen said. “So what the Obama people wanted — a single federal system — will never come to pass.”
The Massachusetts law had distinct advantages, having evolved over nearly two decades and building on practices that were already in place, such as insurers not being allowed to deny coverage to people with preexisting medical conditions. The state law also garnered bipartisan support, as well as industry buy-in.
John McDonough, a Harvard public health professor who helped craft the Massachusetts and federal laws, said he cannot conceive of another health reform model that would have achieved a similar level of progress and gotten through Congress in 2010. The law was a compromise cobbled together with conservative ideas such as the individual mandate and having a competitive market-based plan to appease those wary of a single-payer government-run system some Democrats had advocated.
“The Massachusetts model was the worst possible framework for federal reform,” McDonough said dryly, “except for all the alternatives.”