The Rappaport Institute for Greater Boston’s report on the Community Preservation Act (“Study Says CPA Steers Money to Wealthy Towns,” Inquiries, CW, Summer ’07) is so flawed it is difficult to know where to begin.

While it is true that many communities that adopted the Act initially had higher-than-average income levels, that trend began to change in the fall of 2005. The majority of the 27 communities that have passed the CPA since then are from the middle- and lower-income ranks. Of course, another way to look at those early years is that communities in the highest-growth areas of the state—the Route 128 and I-495 belts, the South Coast, and Cape Cod—saw the CPA’s smart-growth provisions and jumped in first.

The study’s other major flaw is that it sets up fictional winners (communities that have passed the CPA) and losers (those that have yet to adopt it). This fails to recognize that the projects funded under CPA benefit the Commonwealth as a whole, not just the adopting communities. To date, the CPA has been used to create more than 1,000 units of much-needed affordable housing. It has saved more than 8,000 acres of our precious remaining open space to maintain our connection to the natural world. CPA communities have made more than 750 appropriations to preserve our historic assets, a major generator of tourism dollars in Massachusetts.

We hope the Rappaport Institute does the requisite homework on its next report before seeking sensational headlines, and treats the stakeholders it plans to “study” with a modicum of respect and professional courtesy.

Clarissa Rowe
Chair of executive steering committee
Community Preservation Coalition


I am rather disturbed by some of the statements put forth regarding how CPA funds are distributed and used. This is not unexpected. I find that studies emanating from the Rappaport Institute seem overly biased to the developer industry, especially when they involve affordable housing.

As an elected town meeting member, I am aware of the CPA process, but my town, unfortunately, has failed to adopt it. As a result, our real estate transaction fees feed CPA without any return. If cities and towns choose to waive on CPA, it’s their loss.

Now, for the concern as to how it’s used. First, there seems to be an objection to using the money for the renovation of potential affordable units. What happened to anti-sprawl smart-growth development? This objection smells of making sure developers continue to have opportunities for new construction. Why can’t CPA money be spent on rehabbing old mills, school buildings, etc. to provide affordable units?

As for the detailed reporting of fund expenditure, CPA funds are voted on at town meetings, city council meetings, etc. From my experience, town meeting members are very inquisitive about where appropriated money is going, and I’m sure there are citizens in each city that want to know what their council is spending. The need for additional reporting is almost an unwarranted assault on the integrity of our local governments.

Last is the objection to towns using CPA funds to “land bank.” Isn’t that exactly what many of our developers do when buying large tracts and holding them until they provide a high profit opportunity—and in so doing contribute to the increased cost of Massachusetts housing?

The Rappaport Institute and the study’s authors seem to be more interested in enhancing a developer’s welfare program than in allowing the towns that were farsighted enough to adopt CPA to use and administer what they were willing to fund.

I would suggest that the “Robin Hood” designation is aimed at the wrong party.

John Belskis


Dave Denison’s article (“Cost Unconscious”) gives an excellent picture of the cost dilemma facing Massachusetts as it tries to implement its new universal health insurance plan. Uncontrolled health cost inflation is indeed the central problem in our state, as it is in the rest of the nation.

But absent from the comments by the authorities cited in the article was any recognition that the solution cannot be achieved by state action alone. It will require major national health reform, involving a change in the insuring of health care as well as a change in the funding and organization of the delivery of that care. With the right kind of national reform, we could easily afford to cover everyone with excellent care, and support strong academic and research sectors as well.

As I explain in my recent book (A Second Opinion: Rescuing America’s Health Care), the reason US health care is so uniquely expensive is that our health care system is more commercialized, more investor-owned, and more driven to maximize its income than the health systems of any other advanced country. Even “not-for-profit” institutions compete for income and market share in the US health care marketplace. Unless we eliminate, or at least greatly moderate, the commercialism driving our insurance and medical care delivery systems, we will not control rising costs and will not be able to afford the kind of health system we need.

Arnold S. Relman, MD
Professor Emeritus of Medicine
Harvard Medical School


The quote from business writer Steven Pearlstein is dead on: “Lots of powerful interests do nicely with things just the way they are.”

Before the 2006 health care reform law in Massachusetts, skyrocketing premiums had insurers fretting about a “death spiral” as younger and healthier residents decided not to buy pricey coverage. Hospitals worried about the rising bad debt that comes with rising numbers of uninsured patients. The reform law, if fully implemented, addresses the worries of these insurers and hospitals. The individual insurance mandate delivers private insurers the young, healthy members they need, along with something on the order of $1 billion in new revenues after full implementation. Hospitals get an upfront bonus of almost $400 million in reimbursement rate increases from MassHealth and in the protection from bad debt that comes with near universal coverage. The best thing of all, from the perspective of insurers and hospitals, is that they are asked to do nothing in return other than to carry on with business as usual—that is, the inefficient delivery and the uneven quality of care that wastes billions of dollars each year.

In 2005, six months before the current reforms were enacted, advocates for a health care constitutional amendment delivered concrete proposals, prepared by nationally respected health care economist Kenneth Thorpe, that would have cut Massachusetts health care spending by over $2 billion. Those savings would have more than paid for moving to a universal, public-private hybrid health care financing system. The proposals included: a requirement that hospitals use patient safety monitoring systems to reduce medical errors; the requirement that providers better coordinate care for the chronically ill; and a public health initiative to cut the obesity growth rate to zero. Each one of these proposals would improve the health of Massachusetts residents and the bottom lines of hospitals and insurers.

Not one of these proposals was included in the final reforms. If the Thorpe report had any impact at all, it was to galvanize the major stakeholders in their efforts to kill the constitutional amendment. And why not? Instead, they got what they wanted —nearly $1.4 billion without having been even asked to do anything in return. And without the constitutional amendment, there is virtually no political leverage to force change.

If cost-cutting and quality improvement required blazing new trails, then maybe more data collection would be in order. But it doesn’t. Patient safety monitoring systems save lives and have cut inpatient spending by 10 percent to 15 percent in the hospitals that have adopted them. Better coordination of chronic care reduces expensive complications and avoidable hospitalizations.

So far, Massachusetts taxpayers have footed almost the entire bill for reform. Over 90 percent of the newly insured have been enrolled in the MassHealth or Commonwealth Care subsidized plans. All of this new money has been wasted because expanded coverage could have been paid for with the savings from providing better quality care. Instead, last year 2,200 patients died in Massachusetts hospitals from avoidable medical errors at a cost of about $700 million.

How long should we wait?

Barbara Waters Roop, Ph.D.


Imagine that you need to buy a new car and someone gives you a coupon that entitles you to select any car you want. What kind of car would you choose? You would not likely go for the least expensive model you could find. In fact, you’d probably go in the opposite direction.

Now imagine that instead of a coupon, you receive $20,000 toward the cost of the car and are allowed to keep any portion of the money you don’t spend. What would you do? Would you spend more than $20,000 by using money out of your own pocket? Spend exactly $20,000? Or would you spend some of the $20,000 and save the rest? It’s interesting how our desire for information and our ultimate buying decision change when we have “skin in the game.” It’s that skin in the game that is clearly missing from the health care system in Massachusetts today.

Creating a sustainable health care system requires that we shift the debate into new directions that more fully—and responsibly—engage all of us as consumers. Transparency, as discussed in Dave Denison’s article, is a part of the equation. But transparency needs to be defined and supported in the broadest sense possible. The creation of a Web site with cost and quality information (a key objective of the Health Care Quality and Cost Council) is a great start, but it is by no means a silver bullet. Quality and cost data for some Massachusetts providers have actually been available for a few years now, but the information is often represented in ways that only a health care insider can understand. The information has to be presented in a way that works for two key stakeholders in the health care system: patients and their providers.

More fundamentally, we need to link the use of quality and cost data with health insurance plans to better engage consumers financially in their own health care decisions and lifestyle choices. For example, tobacco use and obesity have a significant impact on health care costs, but our system has few financial incentives to encourage non-smoking and a healthy diet. Building those incentives into health plans is a place to start. Our experience at Fallon Community Health Plan shows that even small financial incentives can influence behavior. We believe that applied to everyone, these incentives could bring down health care costs. Will quality and cost data help? Absolutely. But controlling costs while also improving health outcomes depends on giving consumers “skin in the game.” They need the power and the responsibility to make their own informed choices.

Eric H. Schultz
President and chief executive officer
Fallon Community Health Plan


Charles Euchner (“Squeaky Wheels,” The Book Case) has a sort of condescending irritability toward those who oppose the Cape Wind project in Nantucket Sound. He writes that only Kennedys and wealthy sailboat owners oppose the installation of these “toothpicks.” Nicely designed though they are, I cannot love them, and I certainly don’t want the sight of them coming between me and this comforting view of water, sky, and graceful curve of land.

I am used to these windmills. I often see them as I enter Toronto on the Queensway from the west. The sight of these 40-foot-tall white columns doesn’t bother me so much in that setting. Towering over the 19th-century buildings of the Canadian National Exhibition grounds, they prepare one for the miles of high-rise apartments that Toronto has seen fit to erect along its Lake Ontario waterfront. Today, it seems to me, everything is for sale.

So I hope the Kennedys will continue to take it on their chins for the rest of us of more modest means who do not want Jim Gordon’s money-making machines despoiling a beautiful area. It is not necessary to have a house in Nantucket to appreciate the beauty of the island. Anyone can go there, spend the day, walk through the town, and along the beaches, and browse through the shops. Nantucket and Martha’s Vineyard, like the Cape Cod National Seashore, are special places, and we all should strive to keep them “free.”

Judy Carr Johnson
Bradford, N.H.


As your title correctly states (“In Tight Times, Universal Preschool Gets Held Back,” Inquiries, CW, Spring ’07), times are tight. However, contrary to the article’s premise that the effort to expand access to high-quality early education opportunities for all 3-, 4-, and 5-year-olds throughout Massachusetts has diminished in recent years, there have actually been many positive and significant steps taken by the Commonwealth toward achieving this goal.

In 2005, the state created the first-in-the-nation Department of Early Education and Care. Among EEC’s statutory responsibilities is to oversee the development and implementation of voluntary, universally accessible, high-quality early childhood education for all preschoolers in the Commonwealth. To this end, the Legislature appropriated $4.6 million for pilot funding for the Massachusetts Universal Pre-Kindergarten Program (MA UPK) in the fiscal 2007 state budget. This pilot funded 131 grants to programs serving 5,900 children in 62 cities and towns to promote school readiness and to inform the longer-term implementation of the MA UPK program. Despite a challenging budget cycle of significant structural deficits and escalating costs, MA UPK received a $2.5 million (54 percent) funding increase in the state’s fiscal 2008 budget.

The Legislature has also acted upon evidence that the most effective pre-kindergarten teachers have specialized training in early childhood education, establishing the early educator scholarship program in fiscal 2006 with funding of $1 million. This program has awarded 1,273 scholarships to help educators obtain either an associate’s or bachelor’s degree and, thus, improve the quality of early education and care programs for our young children. Due to demand, the Legislature tripled the program’s funding to $3 million in fiscal 2007 and further increased funding to $4 million in the fiscal 2008 budget. Additionally, the Legislature has continued to annually increase investments in full-day kindergarten, Head Start, and the low-income child care programs, all of which represent important elements of the state’s early childhood education and care system. Since fiscal 2005, the Commonwealth has increased investments in early education and care in the state budget by nearly $100 million.

Last session, the Legislature unanimously passed An Act Relative to Early Education and Care, a comprehensive proposal for the effective development of a coordinated system of early education and care in Massachusetts. Regrettably, Gov. Romney vetoed the bill at the end of the session, but the legislation has been refiled and has already been heard before the Joint Committee on Education. Advocates are optimistic that it will again receive the strong support of the Legislature and be signed into law by Gov. Patrick. Most recently, Patrick has introduced the Readiness Project, a group of educators, legislators, business leaders, and community leaders who will work to create a plan that provides universal pre-kindergarten and full-day kindergarten.

The process of ensuring that all young children in the Commonwealth have access to universal pre-kindergarten built upon a mixed system of public schools and private providers is a monumental task and one that requires many systematic and bureaucratic changes to take place before it can be successfully achieved. Our funding recommendations purposely assume a long-term and deliberate roll-out process that ensures that the money can be invested effectively. To suggest that the issue has lost some momentum because large amounts of funding have not been allocated to UPK is inaccurate and fails to appreciate the thoughtful process that the Commonwealth has undertaken to successfully achieve high-quality “early education for all” young children.

Margaret Blood
President/campaign director
The Early Education for All Campaign