A bold insurance experiment
IT IS STARTING before the proverbial ink dries on the healthcare reform bill. The sniping, that is. Along with the second-guessing.
What started out being hailed as landmark legislation -- a national model -- is being nitpicked apart by analysts, pundits, and others. Some questions are legitimate: Is there money enough to cover everyone, can insurers develop plans that are low cost yet provide real coverage? More often, the doubts have to do with whether this is a quixotic solution to an insoluble problem of the kind the Clintons attempted in 1993 and the Dukakis administration in 1988.
The answer to those last questions is a resounding ''no."
We know because we helped forge the 1988 plan -- one of us as Governor Michael Dukakis's secretary of human services, the other as his deputy insurance commissioner. Our understanding of what went right and wrong then, and later, informed the Blue Cross Blue Shield of Massachusetts Foundation's initiation of the ''Roadmap to Coverage" that launched the process resulting in last week's legislation. It also gives us confidence in predicting that circumstances are dramatically different now, in ways that bode well for success.
To start with, there is consensus today that simply was missing 18 years ago.
In 1988, the business community was sharply divided about the reform law, with many leaders and groups vehemently opposed to its employer assessment. The price tag then was $1,680 per worker, in 1988 dollars, for employers not providing coverage.
The current measure imposes a per-worker levy of just $295 for firms that do not contribute to health insurance. That more modest assessment helps explain why most of the business community is actively backing the bill. The prospects for the Commonwealth's economy also are stronger today than in 1988, and business leaders are publicly predicting that the health reform law will boost the business outlook.
The Legislature was deeply divided in 1988, with the bill passing the House by a vote of 77-75 and the Senate by 19-15. Attempts to repeal the employer mandate provisions, which were not scheduled to go into effect for two years, began immediately, resulting first in delays, then in repeal in 1996.
Compare that to this year's legislation, which passed the House and Senate by near-unanimous margins. Senate President Robert Travaglini and House Speaker Salvatore DiMasi led the efforts to approve the bill, and Governor Mitt Romney signed it, albeit while vetoing important features, including the employer assessment. The Legislature will probably override his vetoes. Consumer advocates worked with religious leaders to form a broader-based movement for healthcare reform than ever before, and are optimistic about the bill.
Why the consensus this time? The bill combines approaches from the right and left. Consider the individual mandate, which requires residents to buy health insurance if affordable coverage is available. This idea, initially proposed by the Urban Institute in the Foundation's ''Roadmap to Coverage," is one of the breakthroughs that made a comprehensive reform bill possible.
For political liberals like us, who have long embraced employer mandates, putting the onus on the individual has been hard to accept. But like Senator Edward Kennedy and others, we've become frustrated by the ideological impasse that has prevented progress on health reform for many decades. So we embrace this bill's novel approach of combining an individual mandate with subsidies to make coverage affordable, increased employer responsibility, and Medicaid expansions.
Much work lies ahead. But even as we acknowledge those challenges, let us take a minute to recognize what we have achieved. The bill passed by the Legislature expands Medicaid coverage for children. It restores dental care and other benefits for more than a half million Medicaid members. It creates fully subsidized coverage for people at or below poverty, and partial subsidies for the near-poor. It requires individuals with high incomes who have no health insurance to contribute to a system that cares for all of us.
History shows us that bold new experiments sometimes succeed and sometimes do not. But making life better for people, which is what this bill is about, requires having courage to try something new. With continued strong collaboration and leadership, Massachusetts can be the first state to show the nation that we can achieve health security for all.
Philip W. Johnston is chairman and Nancy C. Turnbull is president of the Blue Cross Blue Shield of Massachusetts Foundation. 
