Massachusetts Health Care Reform – Where the Wild Things Are

A line in Maurice Sendak’s classic – “Where the Wild Things Are” – describes the current situation for the Massachusetts health care reform process: “Let the Wild Rumpus Start!”

Massachusetts is in a wild rumpus of contending forces. It isn’t clear if the rumpus will capsize the reform process, or whether the alliance of government legislature and executive branches, employers, health plans, and citizens, will tame it.

As of this spring, 350,000, or 5.5% of the Massachusetts population is newly insured. This represents approximately half of those who were uninsured at the start of the health care reform process. Approximately half are enrolled in Commonwealth Care, the subsidized program for those who earn less than 300% of the federal poverty guidelines and do not have other insurance options. One quarter have enrolled in employer plans, perhaps triggered by the mandate that individuals must be insured or face a financial penalty. The rest are newly enrolled in Medicaid (18%) or via individually purchased, non-subsidized, coverage (7%).

An excellent New England Journal of Medicine article quotes Jon Kingsdale, the executive director of the Massachusetts Connector Authority, as saying “To maintain public and financial commitment to the new programs, controlling costs is 110% of the challenge for the next several years.” What Kingsdale says for Massachusetts is true for the entire country.

Given the fact that health care reform won’t succeed unless the #1 wild thing – cost – is tamed, it is illuminating to see ambivalence at play in Massachusetts. At the same time that the state is struggling to provide more affordable insurance, it is making decisions that drive costs up! What’s up? Is the state bonkers?

Some months ago the Connector Board – the entity that manages the reform process – decided that “minimum creditable coverage” (the level of insurance required for individuals to meet the mandate), must include prescription coverage. From a health perspective this is obviously the right decision. Meaningful health insurance should provide at least some drug coverage. But from the perspective of cost to the state, the drug benefit is a cost increaser.

And just this week the Massachusetts House overwhelmingly supported a bill that would require insurers to cover virtually all mental health and addictive disorders the same way they cover other medical conditions. From the perspectives of psychiatry, public health, and ethics, this is the correct policy. But as with pharmaceutical coverage, it will drive costs up.

The collision course between insuring everyone, controlling costs, and mandating wider benefits, is a high risk strategy, not an absent-minded inconsistency. Universal coverage and robust health insurance are both important goals. Massachusetts has chosen to embrace both, with the hope that the pressure this creates will energize efforts to contain costs.

From approximately 1980 – 2000, U.S. health policy asked insurers to control costs through selective contracting and utilization management. For a while this approach worked, but the backlash against managed care ultimately shot it down.

Massachusetts is hoping that (a) the population will recognize that (b) it wants universal insurance and broad benefits but that (c) it can’t have both without (d) getting a grip on health care costs and therefore (e) will demand that providers join with other stakeholders to make this happen.

The wild rumpus of cost control in Massachusetts is just starting. Stay tuned to see how it plays out!