Shortly after the ceremonial signing of the bill in early April, Nancy C. Turnbull, president of the Blue Cross Blue Shield of Massachusetts Foundation, co-wrote an editorial with Philip W. Johnston, calling the legislation a “bold insurance experiment.” Both Turnbull and Johnston were part of the Dukakis team that helped create that administration’s 1988 healthcare reform bill, which was later repealed. In their 4/16/06 Boston Globe editorial, the authors noted that the consensus for passing the April legislation bodes well for the plan. Recently, Turnbull said she was still optimistic about the workability of the reform.
Praising The Connector’s “aggressive implementation schedule” (for the expanded Medicaid coverage and the C-CHIP), Turnbull points out that outreach and public education will be key to the success of the plan’s subsidized coverage components. To that end, she anticipates that the Foundation will fund grants to community-based organizations to help them with the “significant new responsibilities” of community outreach to enroll those eligible.
What’s “Affordable?”
The individual mandate deadline is July 1, 2007, and before that date The Connector is charged with making determinations about affordability standards. “Over the next six months,” explains Turnbull, “they will have to decide what portion of household income it is reasonable to expect people to contribute toward health coverage.”
People such as Steffie Woolhandler, MD, MPH, a primary care physician in the Department of Medicine, Cambridge Hospital and Harvard Medical School (Boston) and a co-founder of Physicians for a National Health Program, which favors a single-payer system, worry that insurers will rely on high deductibles and co-pays to make premiums affordable.
“Consumer-directed healthcare is terrible for patients,” says Dr. Woolhandler. And under the payment structure of high-deductible insurance policies, “payment is terrible for docs because most of what we bill is in that early part of spending before the deductible [is met].
“I’m a primary care doc,” she continues, “and most patients who come to my office would be paying out of pocket in that consumer-directed healthcare situation.”
Calling the statute a hoax, Dr. Woolhandler maintains that it won’t achieve universal healthcare, and, in fact, will financially penalize working families.
Turnbull acknowledges that concerns such as those voiced by Dr. Woolhandler are well-founded because insurers and employers have traditionally resorted to increased cost-sharing to regulate premiums. However, she says, “If we don’t find ways to make good coverage more affordable, then the individual mandate will not go into effect for many people.”
Asked what he would say to critics who do not think private insurance companies can structure products that are both affordable and of good quality, Dr. Kingsdale says, “It’s up to them [the insurance companies] to prove you wrong. A well-functioning market with a lot of good information, which is what this reform calls for, can improve upon the plans available to what is perhaps the least well-functioning part of the existing insurance market: the non-group and small-group insurance market.”
Determination of good quality, affordable benefit packages will be a difficult decision. “In my personal view, I think we will have failed if, as a result of the mandate, we succeed only in requiring people to purchase coverage that is not adequate,” says Turnbull, “because then we will have traded ‘un-insurance’ for underinsurance, and that’s not a good policy outcome either.”
I’m glad to see [universal health coverage in Massachusetts] happen. A lot of people have been wondering how we are going to address the issue of the 45 million uninsured in this country. This is one step toward that, but there are really a lot of ifs, ands, and buts on whether it will truly be pulled off in a year or two.
—Joseph Li, MD