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)

The government, for its part, is defining basic coverage and trying to make insurance more affordable. Under its new Commonwealth Care program, it is subsidizing coverage with no annual deductible on a sliding scale for people with incomes of up to 300 percent of the federal poverty level, or $61,950 for a family of four. About 130,000 low-income people are already enrolled either in Commonwealth Care or MassHealth, the state's Medicaid program, state figures show. The poorest pay no premiums.

Those who do not qualify for subsidies and cannot get coverage through their jobs can buy low-cost but unsubsidized health plans offered by private insurers through the Connector under the Commonwealth Choice program. Premiums go up with age, but people cannot be charged more if they are sick or be denied coverage because of a preexisting condition.

Costs are still too high for some. Already, state officials expect to exempt 60,000 residents from the new mandate because they cannot afford the insurance at the going rates, even though they earn too much to qualify for subsidies. That is a big reason that Massachusetts is destined to fall short of universal coverage under the new law, officials say, although proponents say covering 99 percent of residents is possible.

"Affordability is the big question here," said Kathy Swartz, a professor at the Harvard School of Public Health, who noted that even those with a basic plan could face high deductibles. "It's certainly what a lot of other states are wrestling with -- how do you bring the costs down?"

The state's costs are a concern, as well, with some analysts wondering whether Massachusetts will be able to keep funding the $1.6 billion-a-year program if the economy slumps or if costs rise substantially over the next few years.

"This is not an enterprise for the faint of heart," said former Democratic state lawmaker John McDonough, executive director of Health Care for All, a nonprofit group that pushed for the new law. "There are always risks. There are always problems. There are always clouds on the horizon that could turn into a storm. Get used to it."

About 57 percent of all Massachusetts residents say they support making health insurance compulsory, according to a poll released last week by the Kaiser Family Foundation. But two-thirds of respondents said they expect the new law to cause their taxes to increase. And 72 percent said they did not know the deadline for getting coverage. The plain fact is that most residents will not be affected directly by the new law because more than 90 percent already have insurance, often through their jobs or, for the elderly, through Medicare.

Charles Paine, 64, a cab driver from the Boston suburb of Waltham, said he supports the law. Paine, who has diabetes, already receives help from the state and said he expects to enroll in one of the subsidized plans.

"I'm one of the ones they call working poor," he said. "I make enough to get by, but I don't have enough to pay my bills and have health insurance. I think it's ludicrous not to have health insurance for everyone. I don't think you should work your whole life, and get sick, and lose everything you've worked for. It will be tight for me, but I've got to have it."