A sign of bipartisan progress

By Ronald Brownstein Published:

By Ronald Brownstein

Two miracles took place in Massachusetts last week.

First, the state Legislature approved the nations most ambitious effort to expand access to health insurance.

Second, the plan emerged from a process of creative bipartisan collaboration between Republican Gov. Mitt Romney and an overwhelmingly Democratic Legislature.

At a time when Washington, D.C., is locked in partisan warfare on almost every front and has done little to reverse the declining access to health insurance nationwide, its difficult to say which of Massachusetts achievements is more remarkable. Both should inspire not only other states but the federal government as well.

The Massachusetts health plan is an intriguing, innovative, different experiment that really demands attention and respect from folks around the country, said John E. McDonough, a former state legislator who now directs Health Care for All, an advocacy group. It is an amalgam of left and right approaches that I have not seen.

The legislation, which Romney plans to sign this week, aims to provide health insurance to 95 percent of the roughly half a million state residents without it.

As McDonough suggests, the plans secret is that it blends ideas favored by liberals and conservatives into a comprehensive attack on the stubborn problem of the uninsured (who now number nearly 46 million nationwide).

The plans foundation, originally proposed by Romney, defines an important principle of joint responsibility between individuals and government to ensure coverage.

The plan would require all Massachusetts residents to buy health insurance, the way states now require all drivers to purchase car insurance. But the state would cover all the costs for families whose incomes are below the federal poverty level (about $20,000 annually for a family of four) and subsidize premiums, on a sliding scale, for those earning up to three times that amount.

The plan would establish an innovative insurance exchange that would offer individuals and small businesses a variety of policies to purchase. It would provide health insurers more leeway to offer stripped-down, less-expensive policies, especially for young people. It also would expand government-provided Medicaid for children in working-poor families and would require employers who dont cover their workers to contribute to the cost of the state premium subsidies.

That thumbnail hints at the plans brilliant political balancing.

The package advances many ideas dear to conservatives. It enshrines the conservative value of individual responsibility by requiring everyone but the poor to contribute to their own coverage. It would provide that coverage primarily through the private marketplace, not government programs.

It would test (for young people, at least) the conservative belief that insurers will create much more affordable health policies if extensive state mandates to cover specific treatments are loosened. And starting in 2008, it would link payments for health care providers to the results they produce for patients -- an idea gaining ground in both parties.

The Democratic rhetoric has been about getting insurance for everyone, but their answer is always taxes and government takeover, Romney said in a characterization that Democrats, of course, dispute. We took the ideal of insurance for everyone but applied Republican principles: Reform the market, help those who truly cant afford to buy it themselves.

Much could still go wrong. The immediate risk is that coverage would remain too expensive for the uninsured who earn too much to qualify for the public subsidies. The plan would exempt individuals from the mandate if they couldnt find affordable coverage.

The longer-term danger is that the program might grow unaffordable not only for individuals, but for the state, if health-care costs keep rising at their current rate.

The initial projection is that once the program is fully running, the premium subsidies for low-income families will cost $725 million a year. The Bush administration pitched in by allowing the state to apply federal Medicaid funds toward that bill. But if premiums rise faster than expected, the state still might be unable to afford sufficient subsidies to keep insurance within reach of lower-income families -- especially since it has not dedicated any specific source of revenue, such as a cigarette tax hike, to the plan.

Those threats are real. But the Massachusetts plan has created a structure supple enough to respond to the challenges that emerge if the states future political leaders show the flexibility demonstrated by Romney and state Democratic leaders, such as House Speaker Salvatore DiMasi.

Romney, as his comments above show, hasnt renounced partisanship. Neither have Massachusetts Democrats. But both sides overcame partisanship to reach a productive agreement. Thats the most important lesson in the Massachusetts breakthrough.

In the private sector, said Romney, a former management consultant, you dont get anything done inside an organization by battling. You look for consensus and coalition-building and thats what we have had to do here.

2006, Los Angeles Times

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