By Robert J. Samuelson
Monday, July 19, 2010; A15
If you want a preview of President Obama's health-care "reform," take a look at Massachusetts. In 2006, it enacted a "reform" that became a model for Obama. What's happened since isn't encouraging. The state did the easy part: expanding state-subsidized insurance coverage. It evaded the hard part: controlling costs and ensuring that spending improves people's health. Unfortunately, Obama has done the same.
Like Obama, Massachusetts requires most individuals to have health insurance (the "individual mandate"). To aid middle-class families too well-off to qualify for Medicaid -- government insurance for the poor -- the state subsidizes insurance for people with incomes up to three times the federal poverty line (about $66,000 in 2008 for a family of four). Together, the mandate and subsidies have raised insurance coverage from 87.5 percent of the non-elderly population in 2006 to 95.2 percent in the fall of 2009, report Sharon Long and Karen Stockley of the Urban Institute.
People have more access to treatment, though changes are small. In 2006, 87 percent of the non-elderly had a "usual source of care," presumably a doctor or clinic, Long and Stockley note in the journal Health Affairs. By 2009, that was 89.9 percent. In 2006, 70.9 percent received "preventive care"; in 2009, that was 77.7 percent. Out-of-pocket costs were less burdensome.
But much didn't change. Emergency rooms remain as crowded as ever; about a third of the non-elderly go at least once a year, and half their visits involve "non-emergency conditions." As for improvements in health, most probably lie in the future. "Many of the uninsured were young and healthy," writes Long. Their "expected gains in health status" would be mostly long-term. Finally -- and most important -- health costs continue to soar.
Aside from squeezing take-home pay (employers provide almost 70 percent of insurance), higher costs have automatically shifted government priorities toward health care and away from everything else -- schools, police, roads, prisons, lower taxes. In 1990, health spending represented about 16 percent of the state budget, says the Massachusetts Taxpayers Foundation. By 2000, health's share was 22 percent. In 2010, it's 35 percent. About 90 percent of the health spending is Medicaid.
State leaders have proved powerless to control these costs. Facing a tough reelection campaign, Gov. Deval Patrick effectively ordered his insurance commissioner to reject premium increases for small employers (50 workers or fewer) and individuals -- an unprecedented step. Commissioner Joseph Murphy then disallowed premium increases ranging from 7 percent to 34 percent. The insurers appealed; hearing examiners ruled Murphy's action illegal. Murphy has now settled with one insurer allowing premium increases, he says, of 7 to 11 percent. More settlements are expected.
Attacking unpopular insurance companies is easy -- and ultimately ineffectual. The trouble is that they're mostly middlemen. They collect premiums and pay providers: doctors, hospitals, clinics. Limiting premiums without controlling the costs of providers will ultimately cause insurer bankruptcies, which would then threaten providers because they won't be fully reimbursed. The state might regulate hospitals' and doctors' fees directly; but in the past, providers have often offset lower rates by performing more tests and procedures.
A year ago, a state commission urged another approach: Scrap the present "fee-for-service" system. The commission argued that fee-for-service -- which ties reimbursement to individual services -- rewards quantity over quality and discourages coordinated care among doctors and hospitals. The commission recommended a "global payments" system to force hospitals, doctors and clinics to create networks ("accountable care organizations"). These would receive flat per-patient payments to promote effective -- not just expensive -- care. Payments would be "risk adjusted"; sicker patients would justify higher payments.
But the commission offered no blueprint, and efforts to craft consensus among providers, consumer groups and insurers have failed. State Senate President Therese Murray, an advocate of payment change, has given up for this year. "Nobody is in agreement on anything," she told the Boston Globe.
Similar forces will define Obamacare. Even if its modest measures to restrain costs succeed -- which seems unlikely -- the effect on overall spending would be slight. The system's fundamental incentives won't change. The lesson from Massachusetts is that genuine cost control is avoided because it's so politically difficult. It means curbing the incomes of doctors, hospitals and other providers. They object. To encourage "accountable care organizations" would limit consumer choice of doctors and hospitals. That's unpopular. Spending restrictions, whether imposed by regulation or "global payments," raise the specter of essential care denied. Also unpopular.
Obama dodged the tough issues in favor of grandstanding. Imitating Patrick, he's already denouncing insurers' rates, as if that would solve the spending problem. What's occurring in Massachusetts is the plausible future: Unchecked health spending shapes government priorities and inflates budget deficits and taxes, with small health gains. And they call this "reform"?