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PERSPECTIVE

Massachusetts Health Reform: Beauty Is In The Eye Of The Beholder

Abstract

 
The Massachusetts plan to extend health insurance coverage to nearly all of the state’s residents offers several lessons related to health reform, including the following: Bipartisan cooperation is possible; multiple policy mechanisms must be employed to achieve meaningful change; the starting point—in terms of the rate of uninsurance, the degree of insurance market regulation, and so on—matters; and implementation details are critical. In addition to these lessons, we argue that objective analysis and a comprehensive framework for evaluating alternative policy options are needed for similar reforms to be enacted elsewhere.

Lessons From Massachusetts

Top Lessons From Massachusetts Facilitating Reform Elsewhere NOTES

 
Bipartisan collaboration is possible. The first lesson is that bipartisan collaboration, which appears difficult in the polarized U.S. political climate, is possible. What set Massachusetts apart from prospects at the federal level was the willingness of leaders across the spectrum to agree on a common goal (universal coverage) and to compromise, as necessary, to achieve the shared vision. For health reform to get a strong foothold at the federal level, this type of leadership will also be required. Other factors that made bipartisan cooperation in Massachusetts possible—the threat of funding losses; the support of a dominant, private insurance company; and the active promotion of specific reform plans by leading politicians in the state—are not today present in most states or at the federal level. Others have suggested that it will take a major crisis—such as war, severe economic depression, or a serious health threat such as pandemic flu—to foster the conditions for bipartisan agreement.² Perhaps the Massachusetts example will encourage leaders to seek common ground before a crisis forces them to act.

Multiple mechanisms are needed to achieve change. The second lesson is that multiple mechanisms must be employed to achieve lasting change. Policy wonks often talk about "health reform" as though it were monolithic. In fact, the U.S. health care system faces serious problems with respect to health care costs, quality, and access; within each of these areas, multiple actions will be necessary to make improvements. In considering future options for improving the system, the goals of proposed changes should be made explicit as well as the expected impact of individual mechanisms and combinations of mechanisms. The process by which Massachusetts arrived at the final legislation reminds us that legislative bodies will propose different approaches and that these will be altered as bills progress through individual committees, votes by the full legislative body, conference committees, and, for those with line-item veto power, through senior executive–level decisions. The complexity of the individual parts as well as their interactions deserves close analytic attention that is rarely readily available for decisionmakers.

The starting point matters. The third lesson is that the starting point matters (where you stand depends upon where you sit). Massachusetts is unique in its relatively low rate of uninsured residents, its relatively long history and tradition of tightly regulating the health insurance market, the existence of a large federal subsidy, and a state Uncompensated Care Pool. So even if another state were able to pass comparable legislation, the cost and outcomes would likely be quite different, because the state would be starting from a very different place. A better understanding of the starting conditions and the expectations for the future in the absence of major policy change would contribute to making explicit the relative gains and losses likely to be achieved from any proposed change. Today we have no such comprehensive framework for analyzing competing reform options.

Change is driven by implementation. The final lesson is that the real effect of change is driven by how ideas are implemented. Critical aspects of the Massachusetts legislation, such as defining what constitutes "affordable premiums" and the level of subsidies that will be offered, remain to be determined by those responsible for implementation. Although this is certainly not unique to the Massachusetts reform legislation, the real work has barely begun when a piece of legislation is enacted. Those responsible for "interior decorating" frequently lack the tools to help evaluate the likely effects of the different options from which they are choosing. Massachusetts authorities will be charged with finding the right balance between affordable coverage for individuals, appropriate benefit packages, and the revenue requirements (public and private) to finance the plan into the future. And these decisions, in turn, will affect the number of people who voluntarily respond to the mandate, the number who are offered and accept financial assistance from the state in purchasing insurance, and decisions made by employers about the role they will play in offering insurance or financing—that is, the likelihood that Massachusetts achieves its goal of universal coverage. Whatever delicate balance is achieved at the time of initial implementation will be subject to ongoing dislocations as conditions change, including the economic climate, individual and employer responses over time, insurance company offerings, the response of health systems, and future actions at the federal and state levels.

Facilitating Reform Elsewhere

Top Lessons From Massachusetts Facilitating Reform Elsewhere NOTES

 
Although both papers address the question of whether Massachusetts-style health reform can be exported to other states or the federal level, the more interesting question is what will be needed to facilitate discussions of reform options elsewhere. Not surprisingly, we believe that objective analysis within a comprehensive evaluation framework could lay a foundation for common ground. A starting point is to make explicit the outlook for health care costs, quality, and access over the next two decades in the absence of major changes in policy. These projections should serve as the baseline to compare the expected trajectories for public and private financing of health care services under different scenarios and to estimate the effects at both an aggregate level and for subgroups in the population.

Projecting current trends forward. It is common for people to assume that looming problems in health care will not affect them personally. Making explicit who will be at risk in the future and how trends that are already well under way will play out during the next two decades could stimulate an active search for common ground. The analysis should be comprehensive—that is, it should consider health care spending and financing, health care organization and delivery of high-quality medical care, access to health care services and to health, the implications for innovations (technological and nontechnological), and responsiveness to the needs of an increasingly diverse resident population. In other words, providing an analytic framework for understanding the status quo can then be used to construct a variety of "what-if" scenarios that evaluate the aggregate and distributional effects of proposed changes to the health care system. Quantifying the absolute and relative expected impact of change can help reduce the rhetoric that so commonly characterizes debates about these issues; whether covering an additional twenty million people is large or small enough can be left to the beholder to conclude based on his or her own values and expectations. Similarly, developing apples-to-apples ways of comparing the options will facilitate discussions of the most effective ways of achieving common goals.

Research tools. Researchers have a variety of tools at their disposal to help construct a factual basis for future discussions of health reform. Rigorous methods exist for arriving at qualitative assessments (for example, whether a reform will be easy, moderate, or hard to implement) where quantitative assessments are not possible or useful. Among the quantitative methods, meta-analytic techniques and other systematic methods for summarizing existing research can be used to identify parameters for extrapolating future trajectories from prior experience. Microsimulation techniques (static or dynamic) offer another powerful method for estimating likely effects of legislative or private action. For any of these methods to be useful in advancing the policy debate, analysts must be willing to open up their tool boxes and be transparent about the operational definitions and assumptions they used in estimating likely effects. Differences in "facts" are often the result of using different assumptions about critical elements in an evaluation, and the debate that appears to be about fact is really a debate about assumptions.³

WE ARE NOT SO NAIVE as to suggest that good analytics will trump politics. However, serious consideration of health reform at the federal and state levels appears likely, and having appropriate analytic resources available may be a necessary, although not sufficient, condition for facilitating policy change. If nothing else, the public needs neutral, trusted third parties to give the facts. The public in turn can demand of their elected representatives a good-faith effort to find solutions to problems that touch all of us.

Editor's Notes

 
Elizabeth McGlynn (mcglynn{at}rand.org) is the associate director of RAND Health in Santa Monica, California. Jeffrey Wasserman is a senior policy researcher there.

The authors thank RAND and the RAND Health Board of Advisors for their financial support. Any opinions expressed are the authors’ alone.

NOTES

Top Lessons From Massachusetts Facilitating Reform Elsewhere NOTES

 

1. J.E. McDonough et al., "The Third Wave of Massachusetts Health Care Access Reform," Health Affairs 25 (2006): w420–w431 (published online 14 September 2006; 10.1377/hlthaff.25.w420)[Abstract/Free Full Text]; and J. Holahan and L. Blumberg, "Massachusetts Health Care Reform: A Look at the Issues," Health Affairs 25 (2006): w432–w443 (published online 14 September 2006; 10.1377/hlthaff.25.w432).[Abstract/Free Full Text]
2. V.R. Fuchs and E.J. Emanuel, "Health Care Reform: Why? What? When?" Health Affairs 24, no. 6 (2005): 1399–1414.[Abstract/Free Full Text]
3. S. Glied, D.K. Remler, and J.G. Zivin, "Inside the Sausage Factory: Improving Estimates of the Effects of Health Insurance Expansion Proposals," Milbank Quarterly 80, no. 4 (2002): 603–635.[CrossRef][Web of Science][Medline]

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