ON APRIL 12, 2006, then-Gov. Mitt Romney, surrounded by a sea of Democratic officeholders in historic Faneuil Hall, signed historic legislation that put Massachusetts on course to be the first state in the country to ensure health care coverage for nearly all residents.
Twenty years later, 97 percent of Massachusetts residents have health insurance thanks to “An Act Providing Affordable, Quality, Accountable Health Care,” the landmark result of bipartisan cooperation between the state’s Republican governor and Democratic lawmakers. Also instrumental was bipartisan backing from Washington — something hard to imagine today — where a Republican administration and the state’s senior senator, Ted Kennedy, took a keen interest in the law’s passage.
The Massachusetts reform, often referred to by the shorthand “Chapter 58,” for its designation among that year’s laws, served as the model for the Affordable Care Act signed by President Barack Obama four years later. It has cemented the state’s status as the national leader in efforts to make good on the idea that access to health coverage in a wealthy country should be a right, not a privilege.
Two decades later, there is plenty to say about how it came to be, what its impact has been, and what the current challenges are for Massachusetts health care. Today, we are publishing six essays capturing a wide range of opinions on the law.
The one point of agreement among all of them is captured by John McDonough, a pivotal player in the Massachusetts law and the ACA that followed: “Like it or hate it, Chapter 58 mattered,” he writes in his essay.
McDonough tells the tale as well as anyone could, explaining the crucial funding issues that helped get everyone to yes on the reform law. “In the end, it was about money and morality, too,” he says of the converging factors that “opened a window of opportunity for a historic advance.”
A centerpiece of the law was the creation of the Massachusetts Health Connector, the “exchange” marketplace where residents without employer-based insurance or coverage through Medicare or Medicaid could enroll in plans, with significant subsidies available based on income.
“There had never been an organization in Massachusetts, or the nation, quite like the Health Connector, with its complex set of operational and policy responsibilities,” writes Audrey Morse Gasteier, executive director of the Connector.
The Health Connector, she says, had to be both resilient and flexible. “This is an organization that was designed to be on the move and to innovate,” she writes. “The contours of our 20-year history prove that our architects were right to think the Health Connector would need to flex and move and bend; our history shows how we’ve evolved and adapted the way our programs and policies work to meet the needs of the people we’re here to serve.”
Jeffrey Sánchez, who grew up in public housing in Boston’s Mission Hill neighborhood and went on to serve top leadership roles in the Massachusetts House, zeroes in on the law’s significance for those who are often on the outside looking in. “It was the moment the Legislature decided that access to health coverage could not be left to chance,” he writes.
Tiffany Joseph, an associate professor of sociology and international affairs at Northeastern University, points to an aspect of the 2006 law that stood out at the time and is even more noteworthy today: It extended coverage options to documented immigrants with various noncitizen statuses.
Joseph says immigrants nonetheless face a range of obstacles to care. The reason, she writes, “lies at the intersection of race, ethnicity, and legal status — what scholars call ‘racialized legal status.’ Despite Massachusetts’s inclusive policies, structural racism and legal status discrimination have consistently undermined immigrants’ access to care, creating barriers that persist even for those who have coverage.”
While there may be plenty to celebrate about the 2006 law’s nation-leading expansion of health care coverage, Chapter 58 and Massachusetts health care developments that have followed it draw sharp criticism from voices representing the state’s business community and an independent primary care practitioner.
Eileen McAnneny and Rick Lord, top officials at Associated Industries of Massachusetts in 2006, say business community support for the law was premised on a vow that the state would then turn to legislation addressing health care costs. Those efforts, they write, have been woefully inadequate.
“Despite its promising vision, the law’s implementation and the cost-containment legislation that was subsequently adopted have fallen far short of their goals, leading to a more expensive and challenging system to navigate now. Massachusetts has among the highest health care costs in the country, with annual increases consistently outpacing inflation and wage growth,” write McAnneny and Lord.
Jeffrey Gold, a primary care physician in Salem, and Jon Hurst, president of the Retailers Association of Massachusetts, say the law has enabled inflationary health care consolidation, squeezing out independent primary care practitioners, and has been particularly burdensome to small businesses, whose premium costs have soared.
“As Chapter 58 expanded government coverage and mandated subsidized insurance, it created a system that continues to saddle taxpayers and working families with escalating premiums, hospital bills, record-breaking drug prices, and unnecessary hospital expansions,” they write. “High-cost Boston academic medical hospitals have acquired smaller hospitals, primary care practices, and even insurers, creating multi-billion-dollar companies that drive up our premiums and erase competition.”
