Argument

It’s almost a cliché: The Massachusetts health care system is in crisis. Every stakeholder is unhappy. It is not a crisis of technology—new drugs, machines, and methods abound, so that, at its best, medical treatment here is at the cutting edge. It is a crisis of affordability and finance. A new wave of medical inflation is sending shockwaves through the system, exposing it for the Rube Goldberg device it is. The recession compounds the crisis.

Whenever inflation ripples through our gerry-built system, the ranks of the uninsured grow—by 65,000 for every 10 percent jump in employee premium costs, according to the Division of Health Care Finance and Policy. All purchasers of health care, public and private, seek protection from rising prices by cutting coverage and shifting costs to others.

State and federal programs cap access and cut reimbursement rates. Employers raise contribution rates, cut benefits, or drop coverage. Individuals drop coverage, betting that the cost of getting sick will be lower than the cost of insurance; losing often spells financial catastrophe.

Providers often take the first hit from cost shifting, confronting lower reimbursement rates and increased demand for uncompensated care. They try to shift costs back to insurers, who then pass them on to employers and taxpayers, fueling the next round of premium hikes and the next rise in uninsurance. Those with the least bargaining power—low and middle-income working families priced out of the private health-insurance market but earning too much for public coverage—suffer the most.

Today’s recession only aggravates the cycle of rising prices, cost shifting, and growing uninsurance. All the players who can cut back and shift costs do so. The Legislature struggles each year to control state spending and balance the competing demands of stakeholders seeking new funding or programs or ways to cut costs or increase reimbursements. But with about 600,000 uninsured in Massachusetts—644,000 according to the latest US Census data—uninsurance has become a structural problem threatening the health and financial security of Bay Staters; the Commonwealth’s ability to provide key services, like education; business profitability and competitiveness; and the stability of the health care industry, which provides the high quality care we demand and drives economic growth.

The Committee for Health Care for Massachusetts—a coalition of doctors, nurses, patient and health care advocates and community leaders—came together to find a way make sure the Commonwealth addresses this problem head on. Our proposal is straightforward—amend the state Constitution to make our elected officials responsible for guaranteeing every Massachusetts resident access to affordable health insurance. If ratified by the voters, this amendment will mandate action but leave it to our elected officials to design a system that best meets the needs of the Commonwealth—its people, businesses, and health care providers.

Our proposal establishes a principle:
that our elected officials are responsible for ensuring access to affordable health insurance for every resident.

Why a constitutional amendment? The lessons of recent history are clear. A similar constitutional guarantee gave the people a valuable tool to leverage fundamental education and financing reforms in the 1990s—reforms designed by the Legislature with stakeholder input. The mandate the Commonwealth’s founders put in our constitution was essential to forcing those changes.

By contrast, the Commonwealth’s attempt in the 1980s to achieve universal health coverage by legislative means was deeply disappointing. Our elected officials, with stakeholder input, designed and enacted an equitably financed system of coverage for everyone. But the first recession brought repeal of the private funding component, which would have guaranteed coverage for most Massachusetts residents.

Opponents of our proposal say a constitutional amendment is not required to reform the health care system. It’s true that legislative reforms are a legal option—but not a political one. One failed legislative attempt followed by almost 15 years of debate and incremental reforms—reforms that are now be in jeopardy—demonstrate this. Let us be clear: Given the history, new calls for a legislative approach are merely code words for inaction.

Why by initiative? The initiative process is a vehicle for voters to instruct their elected officials to act. Our proposal establishes a principle: that our elected officials are responsible for ensuring access to affordable health insurance for every resident. It does not impose a specific mechanism. Some would prefer that it did. But that would mean circumventing a process that only the Legislature can successfully oversee.

Reform will require cooperation between the public and private payers that finance the current system. It will require balancing the varied and often conflicting interests of the many stakeholders in our health care system. Forging the legal nuts and bolts required to provide everyone access to affordable health insurance is a uniquely legislative function. But the principle that will guide and drive this process forward belongs in the Constitution.

The cost of affordable health insurance for everyone is a legitimate concern. That cost, if any, must, however, be compared to the costs of inaction. Inflation, inefficiency, uncompensated care, and avoidable hospitalization cost billions each year, fueling inflation and uninsurance.

No price tag can be accurate until the Legislature and stakeholders design the new system. Until then, opponents will raise, however disingenuously, the specter of outrageous costs to thwart change.

Some estimates have already been offered, based on the misleading assumption that Massachusetts taxpayers would foot the entire bill for buying individual policies for every uninsured individual—yet many qualify for family plans, many qualify for MassHealth or SCHIP (with 50 percent federal payment), and many could pay some or all of the premium themselves.

These misleading estimates ignore the $700 million taxpayers, hospitals, and employers currently pay for uncompensated care, which could be used to provide better and cheaper care for the uninsured. They assume we can’t cut a dime from the over $16 billion we now spend on administration when reputable studies show that better information management can generate $2.5 billion in savings. They deliberately overlook the $1 billion spent each year for avoidable hospitalizations and assume that providing high quality, coordinated preventive and acute care in doctors’ offices instead of expensive, sporadic care in emergency rooms will not generate savings over time. Reputable research and practical experience contradict these assumptions.

Our proposed amendment is not a blank check—quite the contrary. It mandates an affordable system that roots out waste and inefficiency and reallocates the savings to quality, cost-effective care.

It limits coverage to “medically necessary” care, as all insurers, public and private, do to control utilization and costs. It provides a mandate to do what our elected officials and private stakeholders want most—to get good value for our health care dollar. Cutting waste and inefficiency will produce more resources for direct care, which will make Massachusetts residents healthier and more productive and Massachusetts businesses more profitable.

Lawmakers are understandably wary of adopting a proposal that the Supreme Judicial Court could interpret more broadly than either the Legislature or the proponents intend. But legal precedent suggests the SJC will defer to reasonable legislative interpretation of the amendment.

In the McDuffy educational equity case, the SJC didn’t even issue its opinion that the Legislature had an obligation to act until reform legislation had been drafted. If the Legislature enacts legislation that can reasonably be said to meet the standards set out in the amendment, the SJC is likely to defer. Legislative action within a reasonable period of time following ratification will likely limit litigation to that which accompanies any new law.

Meet the Author
Meet the Author
What the SJC isn’t likely to stand for is inaction. By writing the principle of affordable health insurance into the state Constitution, the citizens will have a powerful judicial ally.

Even opponents of this proposal concede the need for affordable health insurance for everyone. Expanding access and making the system affordable and sustainable will not be simple, but it can and must be done. This constitutional mandate will be a catalyst for getting stakeholders to the table to end the cycles of inflation, cost shifting, and uninsurance that hurt the Commonwealth’s residents and its economy. Our health and prosperity depend on prompt action, and with this amendment, we will get it.

Barbara Waters Roop, PhD, JD, and John D. Goodson, MD, are co-chairmen of the Committee for Health Care for Massachusetts.