Can Massachusetts' Experiment Tell Us What's Next?

Published April 8, 2010

Kaiser Health News

Now that the year-long debate in Congress over health care legislation has come to a close, it's reasonable to ask: What's next?

Some think that enactment will quickly lead to widespread and generally quiet acquiescence to the terms of the new law, even by those who were strongly against its passage by Congress. Perhaps.

But most of the law's major provisions don't get implemented until 2014. Indeed, though President Barack Obama is now daring his adversaries to try to repeal the law's protections and benefits, hardly anyone will see benefits for more than three years. In the meantime, there will be two federal election cycles and plenty of Medicare cuts, tax increases, and insurance premium hikes to inflame passions.

Moreover, the manner by which the legislation was enacted virtually guarantees that the mid-term election this November, as well as the presidential contest in 2012, will become de facto referenda on the health care plan. Put another way, the last words in this debate were not uttered at the law's signing ceremony. Those will be reserved for the voters, when they make their voices heard at the ballot box.

And, as matters currently stand, things don't look particularly rosy for proponents of the new health legislation. In most polls, a plurality of Americans remains opposed to it, even after it was signed into law. Further, the intensity of opposition far exceeds the intensity of support. The bruising and partisan manner by which the bill was pushed through its final legislative stages has further enraged its most ardent opponents. In the end, no Republican supported the final bill, and there's no sign of adverse political consequences for not doing so. The same cannot be said for those many Democrats who supported the bill at various stages despite clear opposition from a majority of their constituents.

Of course, it's a long time to November, and longer still to 2012; anything can happen. But if Republicans do in fact pick up a sizeable number of House and Senate seats and the balance of power in Washington shifts, the consequences for health care policy could be very dramatic. At a minimum, those who are elected on an explicit platform of opposition to the recently passed law would feel emboldened, and probably obligated, to propose a sharp shift in direction, even in the face of unwavering opposition from the administration. How a standoff between the two warring sides would then play out is anybody's guess.

But, assuming for the moment that implementation proceeds as scheduled, what will the future hold?

The president himself has said that the national plan contains many of the features of the Massachusetts program, now operating in its third year. He is right. There are striking similarities between the reform plans, which is why what's happening in Massachusetts today is very instructive.

When Massachusetts rolled out its coverage program in 2007, many more people signed up for the new heavily subsidized insurance than was originally predicted by budget officials. Almost immediately, costs far exceeded what had been budgeted, forcing state officials to scramble to find cuts elsewhere in government and other sources of revenue.

After three years, no real progress has been made on rising costs. The program remains well over budget, with no end in sight. Further, state residents who now must buy state-sanctioned coverage are bristling at their rising premiums and the inability to find coverage which covers less and thus costs less.

State politicians are responding to the cost crisis the only way they know how: by promising to impose arbitrary caps on premiums and price controls for medical services. The governor and state regulators have disallowed 90 percent of the premium increases insurers –all of whom are not-for-profit–submitted for their enrollees for the upcoming plan year. The state says premium increases aboveeight percent are too high and unacceptable, though they themselves don't have a plan to make health care more efficient in Massachusetts. They just want lower premiums. The insurers have responded by refusing to sell any coverage at the rates the state wants to impose.

The way out of this stand-off is predictable: more price controls. To hold premiums down, Massachusetts officials are already laying the groundwork to impose government-set payment rate schedules for services beyond the realm of public insurance.

The risk of cost overruns is even higher at the federal level than in Massachusetts. The Congressional Budget Office projects just 17 million people will be getting subsidized insurance through the state-based exchanges in 2016. But the population with incomes between 100 and 400 percent of the federal poverty line–roughly the group targeted for subsidized coverage–is more like 130 million people. CBO assumes the vast majority of low- and moderate-wage families will stay in job-based plans with no additional federal help. But what if they are wrong? Employers are already looking for ways to shed as much of their health care bill as they possibly can onto taxpayers. If 30 or even 50 million Americans end up in the exchanges, federal costs will soar.

The federal government is already running up debt at an unprecedented pace even before the new health care entitlement has been rolled out. If the health bill's costs exceed projections, the same pressures which have led Massachusetts officials to impose premium caps and price controls as the solution to costs would lead some politicians at the federal level to call for the same approach nationwide. Indeed, the administration has already laid the predicate for just such steps with its proposal to establish a federal insurance rate authority to oversee insurers' premium submissions. That idea did not make the final legislative cut, but it could easily be resurrected in a budget crisis.

And that's the real danger of what's just been enacted. There are only two ways to slow the pace of rising costs: with a functioning marketplace or with government-imposed cost controls. The new health law adopted neither approach in any significant way. But when push comes to shove, it's clear which direction the Obama administration will go to really slow the pace of rising costs, which is the same direction Massachusetts is already heading today–toward heavy-handed price controls. Such controls, however, do not make health care delivery more efficient. They cut costs only by driving out willing suppliers of services. In other words, it's cost control through restricted access to care.

Mr. Capretta is a fellow at the Ethics and Public Policy Center and a consultant to private health insurers. He was an associate director at the Office of Management and Budget from 2001 to 2004.

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