Since Massachusetts passed its reform, the share of residents without health coverage has fallen to 2.6 percent from roughly 10 percent pre-reform. Like the major national bills, Massachusetts law requires nearly all residents to have insurance and provides subsidies to residents who can’t afford to buy it. If your employer doesn’t offer coverage, you can sign up for approved fall-back plans, and you can’t be turned down for coverage because of a pre-existing health issue. In what may be an alarming omen, though, Massachusetts’s program has struggled to cover costs.
MoneyWatch.com contributor Michelle Andrews caught up with Gruber, just as Congress headed home to take up the health care debate with their constituents.
Was it a mistake not to address costs from the beginning in Massachusetts?
The goal was to provide universal coverage, and the truth is that we’ve done so within the budget we set ourselves. The program was never intended to bend the health care cost curve. That’s the next stage. I don’t think we would have gotten this law passed if we’d tried to do it all at once.
Would you say the same about national reform?
The big question at the federal level is, to what extent do you want to hold broader coverage hostage to lower costs?
There are three possible courses of action: a bill primarily about coverage, a bill with cost control, or nothing. If you pass a bill that emphasizes coverage, it will cover 40 million people and will start us down the path to cost control. If you’re not willing to take that leap of faith, there’s a good chance you’ll just get nothing. That’s the trade-off. Should the president sign a bill that doesn’t fundamentally control costs in the long run? I think he should. Others would disagree.
How does passing a bill that emphasizes coverage start us down the path to cost control? Doesn’t it just increase usage and costs by a huge amount?
There are two important points to make here.First, cost control can’t really work without universal coverage, since the uninsured represent a leakage in the system.For example, many of the ideas on cost control work through the insurance incentives— those can’t work on the uninsured. Second, broadening coverage takes that issue off the table, politically speaking, and moves all the focus toward cost control.We’ve seen that happen in Massachusetts.
Wouldn’t it actually be harder to get a bill passed without cost controls?
In broad terms, the bill would be more appealing with cost controls, so there is something in there for everyone.On the other hand, cost controls may imply limiting the income of providers, which could create new opposition to a bill.
How appropriate is it to use Massachusetts as a model for national health reform?
The difference is, it’s just cheaper to do here. We had a low rate of uninsurance, and we were already spending a lot to cover the uninsured. But as John McDonough of Health Care for All said, the national process is just like the Massachusetts process, only with three more zeros. Massachusetts is proof that the model can work.
Really? Massachusetts residents report increasing problems finding doctors who will see them and getting timely appointments.
There was a doctor shortage in Massachusetts even before health care reform. It may have gotten somewhat worse now, although the evidence is still limited. We have a crisis in primary care in this country in that we don’t have enough doctors; adding 46 million people is only going to make that problem worse.
One criticism of the national proposals is that they must do more to discourage unnecessary services and promote quality. Could the Massachusetts approach be a solution at the national level?
Not only could it be, it has to be the solution. If we’re going to remain in a private system, a system that reimburses providers based on volume of services has to change. Fundamentally that means bundling reimbursements for all providers into a single payment for a given ailment to discourage unnecessary tests and other procedures, and reimbursing providers based on the quality of care delivered. Massachusetts passed cost control legislation in 2008 that set up a commission to review the state’s payment methodology, and the commission’s report calls for a move to this type of reimbursement strategy.
A recent report found that patients in Massachusetts could be hit with huge out-of-pocket costs for relatively common medical problems. Wasn’t health reform supposed to prevent this?
They found some very extreme examples. They did a useful service, though, because the report pointed out in extreme cases that there are holes in the law. We set an out-of-pocket maximum patient contribution of $5,000, but did not include drugs in that. The researchers picked an example that could rack up tens of thousands in drug costs. We’re working to fix that.
What are the strengths of the reform proposals that have emerged to date?
The House and Senate HELP [Health, Education, Labor & Pensions] bills are pretty good. In Massachusetts, probably the single biggest flaw has been that we didn’t subsidize people above three times the poverty line. So we had to exempt about 75,000 people from the mandate to buy insurance. In Congress, by contrast, the reform proposals go up to four times poverty. That’s good. The proposals feature exchanges to buy insurance, which are good, and a mandate, which is effective.
What do you think the chances are that we’ll see comprehensive health reform in the U.S. this year?
Fifty-fifty. You’ve still got some Republicans in the room discussing it, and the president is very engaged. It’s far from over.
