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How They Would Change Health Care: Obama

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By Amy Goldstein
Washington Post Staff Writer
Wednesday, October 29, 2008

BOSTON -- On the ninth floor of an office building just off the Boston Common, a group called Health Care for All runs a help line that, not long ago, got 40 calls a month. Today, the calls each month have swelled to 3,000, as people throughout Massachusetts phone in for guidance in navigating a state experiment in health reform that is the most ambitious in the country -- and a test of Sen. Barack Obama's vision for reshaping health care nationwide.

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Kate Bicego, the help line's manager, slipped on her headset one recent afternoon as a call came in from Travis Lynn, a 26-year-old from Jamaica Plain with asthma and a part-time job at an old movie theater. He wanted to renew his enrollment in Commonwealth Care, government insurance that Massachusetts now offers adults who cannot get coverage through their work or afford it themselves. After a few questions, Bicego told him: "So, it sounds like you will still be eligible . . . premium-free, with vision, dental and medical."

Lynn is one of 439,000 people here who have gained insurance since Massachusetts embarked two years ago on a path to near-universal coverage. More than half of them are paying toward it; the rest, like Lynn, get it free. How close Massachusetts can come to its goal -- and what obstacles it encounters -- is significant, because its strategies resemble much of the approach to health care that Obama has said he would pursue if elected president next week.

Obama says he would keep the familiar arrangement in which most Americans get health insurance through their jobs, as Massachusetts is doing. Yet he also favors profound -- and controversial -- changes that Massachusetts also is putting in place: Expanding government insurance programs and subsidies. Requiring employers to offer their workers coverage or face penalties if they do not. Forbidding insurance companies to reject anyone or charging more if they are sick. Creating a national health insurance exchange to help people to find and compare private insurance policies on their own.

In the most significant departure from the Democratic nominee's thinking, Massachusetts has imposed a mandate that requires most adults to carry health insurance -- and fines them if they refuse.

In the 31 months since the experiment here began, the share of working-age people without health insurance has plunged -- from 13 percent to 7 percent by one estimate -- more sharply and quickly than anyone expected, leaving Massachusetts with the lowest uninsured rate in the country. But the unexpected number of people also has translated into higher-than-expected costs. Massachusetts has been forced twice to scrounge for extra money, totaling more than $250 million this year and last, from state funds and other places.

There have been more unintended consequences. The large number of people who have gotten insurance and are suddenly looking for care has aggravated a shortage of family physicians and other primary-care doctors. A reshuffling of federal and state money, to help pay for the extra insurance, has pulled funds away from some hospitals and clinics that have long been havens for poor patients.

Hard as it was to enact Chapter 58, as the health-care law here is known, the work of putting the plan into practice is proving even more rigorous, according to state officials, business leaders, health-care providers and community activists. The law left unanswered polarizing questions, including who should be eligible for subsidies, what benefits must be included and whether some people should be excluded from the mandate.

"It isn't like you come up with a perfect plan and turn it on and see how it works," said Brian Rosman, research director at Health Care for All, the nonprofit that runs the state's largest private health help line. "Washington needs to understand that as well."

"This is all really a journey," said Nancy Turnbull, an associate dean at the Harvard School of Public Health and member of the governing board of the Health Connector, a new agency created out of the law. "Every time we make one of these decisions, we take a leap of faith."

Whether what is unfolding in Massachusetts could be replicated in Washington during an Obama administration is, people here say, an open question. The law that emerged in 2006 from the gold-domed statehouse on Beacon Hill was the product of an unusual alignment of outside forces, motivations of key players, and the local health-care climate.

Massachusetts's lawmakers had been warned that federal health officials would take away $385 million a year in money for poor patients unless the commonwealth found a different way to spend it. And on the streets of Boston, an influential coalition -- community activists, hospitals, doctors, unions and hundreds of religious groups -- had gathered signatures for a popular ballot initiative that, if the legislature did not act, could have rewritten the state constitution to make health care a right.


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