How They Would Change Health Care: Obama

Then-Gov. Mitt Romney, a Republican on the cusp of his own presidential campaign, was calling for a "culture of insurance" as he sought tangible accomplishments. At the same time, Massachusetts faced a smaller challenge than much of the country, with fewer uninsured residents to start with and fewer undocumented immigrants, who cannot qualify for help.

Even under such favorable circumstances, Chapter 58 was stalled in the legislature for months, as businesses balked at the prospect of penalties for not insuring their workers. That fractiousness was still in view the April 2006 day that Romney staged a theatrical bill-signing in historic Faneuil Hall; he vetoed that part of the law, although lawmakers later restored it.

The Health Connector -- similar to the health exchange Obama envisions to help people shop for private health plans or a new public one -- was created to run the new programs and shepherd the reforms. One of its first tasks was to spread the word that Massachusetts now required insurance. It set up a booth at Boston's beloved Fenway Park. Banks, supermarkets, buses, cable television and grass-roots groups chipped in. Buying health insurance "is a grudge buy," said Jon Kingsdale, the Connector's executive director, "that has to be actively sold."

The sales pitch worked better than imagined, because the state had underestimated how many people were uninsured. After the first year, 176,000 people -- 40,000 more than predicted -- had rushed into Commonwealth Care, the program Lynn joined that provides free coverage or subsidies.

Even now, some residents go without health insurance. Some are offered coverage through their jobs but cannot afford it. The law does not allow subsidies for them. In fact, the Connector board agreed to exempt from the mandate about 60,000 people, some in that group and others with incomes too high for Commonwealth Care but too low for private insurance.

The effect of requiring insurance, the biggest difference from Obama's plan, is a matter of debate. Neera Tanden, his campaign's director of domestic policy, said of his plan, "With a mandate or without a mandate, we are dramatically expanding coverage."

Here in Boston, the common wisdom is different. "The mandate has been an overwhelming influence," Kingsdale said. The price of refusing to get insurance is climbing: from a $219 tax penalty for 2007 to as much as $900 this year.

Last year, MabelSarah Lubogo, 43, a certified nurse's aide who rents a one-bedroom basement apartment in Belmont, paid the $219, figuring it was less than the price of insurance. She used to get coverage through an office job. When she switched work four years ago, she looked for a policy by herself but found them too expensive. Last year, she went to a hospital emergency room twice with unexplained fevers -- leaving her with $4,000 in bills she still is paying off.

This year, a letter arrived from the state saying Lubogo would be fined $75 a month if she didn't get insurance. She called a phone number she saw on television and signed up for a Commonwealth Care plan that costs her $167 a month. With fibroids that need treatment, she said, "I'd rather have something to help me along."

Across Massachusetts, there has been little hint of backlash against the requirement. Public support for the law, high when it passed, has risen since then, surveys show.

The mandate on individuals appears to be having a greater effect than the pressure on companies. "Fair share" fees that businesses must pay if they do not offer coverage are substantially smaller than the cost of helping workers with insurance premiums. The proportion of Massachusetts companies providing insurance, higher than in many states, has barely changed.

The largest lingering question here is whether Massachusetts, having already made big strides in insuring people, can solve the more intractable problem of health-care costs. Chapter 58 "didn't do anything with cost containment," said Massachusetts Senate President Therese Murray (D). "We can't sustain the costs the way they are."

This year, Murray pushed through a second phase of health reform, intended to constrain spending and expand the supply of primary-care doctors to take care of newly insured patients. Debate still swirls whether this second law, two months old, will help.

In the meantime, the emphasis here on insurance is producing results, imperfect as they are at times. Travis Lynn, who renewed his Commonwealth Care coverage through the help line, was dismayed last winter when the program dropped him because he briefly had a higher-paying job. It took him months to get his coverage back, even though he had quit that job because he was unable to walk for weeks after surgery he needed from stepping hard on a plastic champagne glass at a New Year's Eve celebration.

Jaclyn Michalos believes Commonwealth Care saved her life. A waitress and high school field hockey coach who will turn 29 next week, she had a teaching job right out of college that came with insurance. After she left teaching, she signed up for a policy on her own. It cost $500 a month, nearly one-third of her income. As soon as the first bill arrived, she wrote to the insurance carrier to cancel it.

So Michalos had been uninsured for two years when she noticed a lump in her left breast. "I saved up my money," she said, and went to a doctor, who told her not to worry about it. Still, the lump persisted, and a few months after Michalos joined Commonwealth Care, she went for a physical with a new doctor, who referred her for tests that diagnosed her breast cancer.

Commonwealth Care covered her double mastectomy and silicone implants. She did not pay a thing.