The proponents of a state constitutional amendment to establish an individual right to comprehensive health insurance, enforceable against the Commonwealth, have clearly given a lot of thought to the problems besetting our health care system. Apparently, however, they have given no thought at all to how those problems might be solved. Instead, they offer a very dangerous political ploy.
Their proposal is political in two senses. Explicitly, it is a device to force the state Legislature to immediately reshape our health care system—risky enough, one might think. The implicit political aim is much worse: to induce voters to approve a general statement of principle without regard to its practical consequences. A constitutional amendment creating an entitlement will inevitably produce irreversible legislative and judicial results that, though to a significant extent unpredictable, are certainly not anything the public would willingly entertain.
What are these consequences? In the absence of a real plan, we can only speculate, based on a review of the three general approaches to universal coverage: incremental, individual mandate, and single payer. This sobering exercise quickly reveals just why the amendment’s proponents avoid specifics so assiduously.
The incremental approach, which we are now pursuing, has worked to extend insurance coverage to specific populations, but is hardly suited to fulfilling a constitutional mandate for universal coverage. An employer mandate to provide health benefits for all employees, a key component of more extreme incremental approaches, has won initial approval in a number of states, including Massachusetts, only to be abandoned because of its negative implications for economic competitiveness and jobs. This employer requirement is in place only in Hawaii, which has no neighbors and whose economy is based on industries that cannot readily relocate to New Hampshire or Arizona—but Hawaii’s uninsured rate has nevertheless remained comparable to ours. Not only has this approach been rejected here and elsewhere, where implemented it has failed to deliver.
The second approach is an individual mandate, hinted at by the proponents, which would require everyone to purchase health coverage, with state assistance if necessary. This is analogous to auto insurance—except that there would be no choice about participating; some people opt not to have cars. Also, the language of the proposed amendment requires insurance providing “coverage for all medically necessary preventive, acute and chronic health care and mental health care services, prescription drugs and devices.” Individuals forced to buy health insurance would have no option other than the most high-end, comprehensive policy (Lincoln Navigators for all!) at an exorbitant cost, either to the individual or to the state, which would have to subsidize this purchase for those who can’t afford it.
The third approach is a “single payer” plan, which might involve a state takeover of insurance and reimbursement or even a completely government-run health system. But the state’s track record on the insurance program it already runs is nothing to brag about. The Commonwealth is currently funding its MassHealth obligations at about 70 cents on the dollar, to the great distress of hospitals and other providers. The touted administrative efficiencies of single-payer insurance amount to one-time savings approximating a single year’s increase in health insurance premiums, hardly enough to finance coverage for half a million uninsured.
A more direct government takeover of health care would produce a system that is not only compulsory, but monopolistic, with much less independence for physicians and patients, and much more control vested in bureaucracy. In Canada, most private health insurance is banned, prices are controlled, and physician fees are set by government. Waiting times for referrals are high and rising, far beyond anything that would be accepted here. Tellingly, Canadians favor their system in principle, but are deeply dissatisfied in practice.
It is clear that any plan to achieve universal health coverage would entail radical changes to our existing health care system—especially if the promised savings are to be realized. The public has a right to some sense of what those changes would be, and what they might cost; the proponents of change have a responsibility to offer a vision, rather than calling for a leap in the dark. It simply will not do to say, “No price tag can be accurate until the Legislature and stakeholders design the new system,” and to reject all attempts at analysis. No state, no household can afford to conduct itself that way. In the absence of a real plan, the test is not “accuracy” but reasonableness—and the estimates I have seen are reasonable attempts to assign some dollar values to an intentionally slippery proposition.
Even the highest estimate, up to $47 billion (twice the size of the entire state budget), easily meets the test of reasonableness. This figure comes from an independent academic study prepared before the present proposal was advanced, and it takes account of the certainty that if Massachusetts were the only state with universal coverage, it will find itself caring not only for its current population, but for an influx of people from other states who lack insurance and need very expensive treatment. The figures that are flimsy are the ones used by the proponents to claim offsetting savings. What they are really asking the voters for is a blank check.
Who will decide what the new system is like, and what it will cost? Ultimately, the courts. The proponents, enthusiastic about legislative control, cite the constitutional case on education (Webby, McDuffy, nowHancock) as an example of judicial restraint, which it surely is not. The case has been in the courts for 26 years. The Supreme Judicial Court’s 1993 decision has required the Commonwealth to expend billions of additional dollars on education, and the April ruling that children in poor districts are still shortchanged educationally could force legislators—who are already struggling to balance the state budget in a difficult economy—to labor under a huge new spending mandate. Because the enterprise of public education for children is only a fraction of the size of the health care system treating everyone, the fiscal exposure on health could be much greater.
Following the failure of national health care reform a decade ago, Massachusetts and other states returned to the local, incremental approach to extending insurance coverage. The business community has supported and continues to support this strategy, which has been successful in reducing lack of coverage among our citizens. True universal coverage, however, can only be achieved on the federal level. A single state is too constrained by federal law, by resource limitations, and by competitive economics to take this plunge alone—and to do so by constitutional mandate, with no option of changing course, is to court disaster.
To apply a constitutional amendment, the bluntest of political instruments, to something as delicate as our health care system is incredibly risky. Four years ago, voters narrowly rejected a ballot question that would have swept away the existing health insurance system as a way to force legislative action. This proposal, perhaps less threatening on the surface, is, if anything, even more dangerous. It deserves to be rejected as well.
Richard C. Lord is president and CEO of Associated Industries of Massachusetts.