[Marxism] Massachusetts Faces a Test on [Mandatory] Health Care By KEVIN SACK-NYT
giobon at comcast.net
Sun Nov 25 13:43:07 MST 2007
Massachusetts Faces a Test on Health Care
By KEVIN SACK
November 25, 2007
BOSTON, Nov. 20 As the Democratic presidential candidates debate whether
Americans should be forced to obtain health insurance, the people of
Massachusetts are living the dilemma in real time.
A year after Massachusetts became the only state to require that individuals
have health coverage, residents face deadlines to sign up or lose their
personal tax exemption, worth $219 on next year¹s state income tax returns.
More than 200,000 previously uninsured residents have enrolled, but state
officials estimate that at least that number, and perhaps twice as many,
Those managing the enrollment effort say it has exceeded expectations. In
particular, state-subsidized insurance packages offered to low-income
residents have been so popular that the program¹s spending may exceed its
budget by nearly $150 million.
But the reluctance of so many to enroll, along with the possible exemption
of 60,000 residents who cannot afford premiums, has raised questions about
whether even a mandate can guarantee truly universal coverage.
Additional concerns have been generated by projections that the state¹s
insurers plan to raise rates 10 percent to 12 percent next year, twice this
year¹s national average. That would undercut the plan¹s secondary goal of
slowing the increase in health costs.
³We¹re going to be very aggressive in trying to get those numbers down to
single digits,² said Jon M. Kingsdale, executive director of the
Commonwealth Health Insurance Connector Authority, the agency that markets
the subsidized insurance policies. ³If we continue with double-digit
inflation, I don¹t think health reform is sustainable.²
The state¹s experience should be instructive to the presidential campaigns,
and to officials in California, where Gov. Arnold Schwarzenegger, a
Republican, has proposed a similar plan. Democratic leaders there initially
rejected an individual mandate because labor unions argued that workers
might not be able to afford coverage. They have recently reversed course,
but have yet to agree with Mr. Schwarzenegger on how to finance the plan.
Each of the three leading contenders for the Democratic presidential
nomination has pledged to achieve universal health coverage, which polls
show to be a priority for party voters. But as the candidates seek to
differentiate themselves, a rift has emerged over whether it is possible to
insure all Americans without requiring them to obtain coverage.
[WHAT CLINTON, EDWARDS AND OBAMA THINK:]Senator Hillary Rodham Clinton of
New York and John Edwards, the former North Carolina senator, support a
mandate. It is, they say, the only way to guarantee that everyone is covered
and to thereby bring down costs by spreading the country¹s insurance risk as
broadly as possible.
³The sad reality is that the uninsured don¹t just struggle with costs
themselves, they impose costs on the rest of us,² Mrs. Clinton said in
September. ³It¹s a hidden tax: the high cost of emergency room visits that
could have been prevented by a much less expensive doctor¹s appointment, the
cost of unpaid medical bills that lead insurance companies to raise rates on
the rest of us.²
Mr. Edwards echoed those remarks a week later. ³The reason the mandate is
necessary is because you cannot have universal health care without it,² he
said. ³Does not exist, and anyone who pretends it is, is not being
Senator Barack Obama of Illinois sees it a different way. He argues there is
danger in mandating coverage before it is clear it can be affordable for
those at the margins. While Mr. Obama does not rule out a mandate down the
road, his emphasis is on reducing costs and providing generous government
subsidies to those who need them. He would mandate coverage for children.
That distinction set off a pointed exchange in the Democratic debate in Las
Vegas on Nov. 15. ³I don¹t think that the problem with the American people
is that they are not being forced to get health care,² Mr. Obama said. ³The
problem is they can¹t afford it.²
Mrs. Clinton jabbed back, saying Mr. Obama¹s plan ³starts from the premise
of not reaching universal health care,² a virtual slur in the Democratic
campaign. Mr. Obama responded that Mrs. Clinton had yet to explain how she
would enforce a mandate. ³She is not garnishing people¹s wages to make sure
that they have it,² he pointed out.
Obama strategists had been considering that point of attack for several
weeks. It served the purpose, they said, not only of separating the
candidates on a crucial domestic issue, but also of reinforcing their
message that Mrs. Clinton does not, in Mr. Obama¹s words, provide ³straight
answers to tough questions.²
Mrs. Clinton discovered the peril of revealing too many policy details in
1993, when the 1,342-page health plan she developed for her husband
attracted a legion of opponents. This year, she has said she would leave the
particulars of enforcement to her negotiations with Congress.
The Massachusetts plan was signed into law by former Gov. Mitt Romney, who,
like each of his rivals for the Republican presidential nomination, does not
now support a national insurance mandate. The law, which requires adults to
be covered by Dec. 31, grants exemptions from the penalty if an income-based
formula determines that coverage would not be affordable.
State officials warned that if policies were not bought this month they were
not likely to be in effect by the deadline. But some insurers said they
would sell last-minute policies.
The state established a mild penalty for the first year: the loss of the
$219 tax exemption. But in the second year, the fine can amount to half the
cost of the least expensive policy available, probably at least $1,000.
Ann F. McEachern, 33, a waitress and student who lives in Cambridge, said
she did not buy insurance this year but probably would in 2008. ³The penalty
in 2007 wasn¹t enough to kick it up to the top of my priority list,² Ms.
McEachern said. ³It¹s always nice to be insured, but I think I¹m at pretty
low risk for anything happening to me that would be financially
Though officials do not yet have data to determine who the remaining
uninsured are, they assume many are in the group they call ³the young
³At 27, it¹s not like I¹m thinking, Oh, man, what if I need an operation
down the line?¹ ² said Samuel B. Hagan of Lenox, a courier who remains
uninsured. ³Furthest thing from my head.²
John E. McDonough, executive director of Health Care for All, an advocacy
group based here, said he found it breathtaking that political leaders were
calling for an individual mandate well before there was any way to measure
the success of the Massachusetts experiment.
But Diane Rowland, executive vice president of the Henry J. Kaiser Family
Foundation, which studies health policy, said it had become broadly accepted
³that an individual mandate is the only alternative to government provision
of coverage if you hope to achieve universal coverage.²
That said, even Massachusetts officials acknowledge that their universal
coverage plan is not likely to be universal anytime soon.
³There¹s good evidence,² Mr. Kingsdale said, ³whether it¹s buying auto
insurance or wearing seat belts or motorcycle helmets, that mandates don¹t
work 100 percent.² He added, ³We¹re talking about how close you can get to
100 percent, and to me it¹s pretty evident you can¹t get as close without
the mandate as you can with it.²
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