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April 06, 2006

Eye on MA

Folks have been asking for a more thorough run-down on the MA universal health care plan, and since I am the Wesley to all you Buttercups, I'll oblige. If you need a refresher on what the bill looks like, see my post from yesterday. If you want an in-depth look, see Leif Wellington Haas's excellent overview. And if you want my verdict, a thousand apologies, but it's just too early.

The MA plan, of course, is not my ideal. It's an individual mandate, which is better than an employer mandate, but worse than instituting government-sponsored health care. The subsidization scheme looks sound and relatively generous, but that'll depend on funding from year to year. As Nathan Newman notes, it's a bit odd to have the penalty for an individual refusing insurance rest at $1,000 while a negligent employer is docked under $300. But to some degree, that's all optics: MA should've totally sliced the Gordian knot connecting health care to employers and simply adjusted the necessary taxation and subsidization schemes accordingly. Little is more anti-worker than forcing them to depend on their employer for medical care.

The real test of the plan will come in two parts: funding and regulation. Funding because, as Eileen McNamara points out in the Boston Globe, the program has no dedicated revenue stream, and it can fall prey, as Michael Dukakis's plan did, to the funhouse politics of the yearly budget. Truth be told, though, I'm not actually that worried about the funding. Presidential hopeful Mitt Romney wants this accomplishment too bad to deny it the promised operating budget, and the Democratic legislature certainly won't kill their baby. Add in that Massachusetts has a large and advanced pro-health care lobby that will fight for the program's actualization, and I think the little guy will get his allowance right on schedule.

More interesting is how serious the regulation will be. The danger in an individual mandate plan -- as Matt Holt has explained -- is cream-skimming, the insurance industry's nasty habit of herding the young and healthy into cheap, high-deductible plans and sectioning the old and/or ill into unaffordable, stingy policies. Generally, that prices folks out of the market, but with an individual mandate, they can't really opt-out without paying a serious penalty. The answer is heavy regulation of the insurance industry, forcing them to stop "underwriting" plans based on individual health histories and risk factors and begin offering pools based on the community average. Insurers don't like doing this because it cuts into their profits drastically. They could be smacked into shape by the long, open palm of the law, but that presupposes a willingness on the part of the MA government. Spare the rod, spoil the insurer.

Unfortunately, I think MA will, for now, spoil the insurer, so I'm not as enthused as I could be. But the plan is nevertheless a step in the right direction, and new regulations can be imposed if the situation turns dystopic. With Romney on his way out and a Democrat likely to replace him, I'm cautiously optimistic that what's currently a slight improvement to the status quo could emerge a truly laudable example of comprehensive reform. But, for now, it's a decent structure with the wrong incentives: the penalty for lacking care is too low, the likely cost of care will be too high, and the state isn't addressing the pernicious insurance practices that drove so many out of the market in the first place.

Crossposted from Tapped

April 6, 2006 | Permalink


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Unfortunately, this is politics not a fairy tale, where nothing is perfect. Especially not when the credit for it is given to a Republican presidential candidate! A friend of mine thinks that criticism of this shows that liberals are impossible to satisfy because after 5 full years of bullshit, we've finally gotten something we've wanted. But I'm just not sure if this is something we've actually wanted.

I suppose at the very least, the state's adoption of such a plan further brings UHC into the national eye (ABC lead off with it last night) which is a good enough benefit in and of itself.

Posted by: Adrock | Apr 6, 2006 4:39:54 PM


Under current Massachusetts law, medical underwriting in the individual market is not allowed. It's all guaranteed issue and community rated. If you don't have coverage for more than 60 days, insurers can bar you from receiving non-emergency care for 6 months after you've been paying premiums but no longer. The only factors a company selling insurance to the individual market (and there are really only 3--all nominally non-profit: Blue CrossBLue Shiel, Tufts and Harvard Pilgrim) may consider are (1.) the age of the individual and (2.) his / her zip code.

So, for the health insurers this is a pretty good deal. Right now, they're stuck with all the unhealthy people who want to have insurance. They're about to get an influx of healthy people who will be required to buy their product.

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