Massachusetts Begins Universal Health Care

"This is not an enterprise for the faint of heart," said John McDonough, head of a group that backed the health insurance law. (By Christopher Lee -- The Washington Post)

BOSTON -- There is a lot of talk about overhauling health care in the United States, but Massachusetts is actually trying to do it -- again.

Today, the home of some of the nation's most prestigious hospitals and medical schools becomes the first state to require its residents to have health insurance or face financial penalties. Making insurance mandatory -- and more affordable -- for Massachusetts's 6.5 million residents is the centerpiece of a law approved by the legislature last year that civic and business leaders hope will dramatically reduce the ranks of the state's 400,000 uninsured and the number of people who seek costly "uncompensated" care in hospital emergency rooms.

This is not the first time the state has attempted to tackle the problem. Nearly 20 years ago, then-Gov. Michael S. Dukakis signed universal health-care legislation that was supposed to bring coverage to everyone by 1992. But the law's requirement that employers provide coverage to workers or pay a tax proved unpopular, and it was never implemented.

Still, Massachusetts's new grand experiment could become a model for major changes in health care across the country -- if it works.

Already Democratic presidential candidates are borrowing some of its elements for their campaign platforms, Gov. Arnold Schwarzenegger (R) is pushing a similar plan in California, and other states are watching closely.

President Bush signaled last week that state experiments such as Massachusetts's will play a key role in remaking a U.S. health-care system that he described as too costly, too confusing and leaving too many people uninsured.

"States should make reforms to ensure that their citizens have access to basic private health insurance," Bush said after meeting with health-care experts at the White House. "If we want a better system, the federal government has got a responsibility to reform, and so do states. . . . The choices we make now will set the direction of medical care in America for years to come."

Their place in the national spotlight is not lost on the Massachusetts officials, business leaders and consumer advocates who forged an unlikely alliance to get the law passed in April of last year. They know that would-be reformers around the country are hoping that they will succeed, and that skeptics were quick to cluck over early reports this spring that the new state-facilitated insurance plans might be unaffordable for average residents.

"They might like to imitate us, some of them, but a lot of them can't wait for us to fail," said Jon Kingsdale, executive director of the Commonwealth Health Insurance Connector Authority, the new state entity implementing the law. "It's actually very helpful pressure, because people in Massachusetts feel the pressure of the national eyes on us, so they are particularly concerned that this not fail. It actually gives us more momentum."

Although July 1 marks the beginning of the "individual mandate" -- the legal obligation to obtain health insurance -- the real deadline is Dec. 31. When Massachusetts residents file their state tax returns next spring, they must certify that they had acceptable coverage as of the end of 2007 -- or lose the $219 personal exemption. The penalty grows steeper in subsequent years, big enough, officials hope, to persuade most holdouts to get coverage.

The state's 175,000 employers have to pitch in, too. Businesses with 11 or more full-time employees that do not offer health insurance must pay an annual "fair share" assessment of $295 per employee. And businesses must arrange to allow workers to pay health insurance premiums with pre-tax dollars.

"We need to be fair and lenient in terms of enforcement both on employers and individuals in the first year in order to not incur some kind of a backlash," said Richard C. Lord, president of Associated Industries of Massachusetts and a member of the Connector board. "We need to . . . give everybody a chance to adjust to the new realities."