Mass. health care reform turns 10

A conservative think tank idea now reviled by the right

APRIL 12TH IS the 10th anniversary of the signing of Chapter 58, Massachusetts’s landmark universal health insurance law (An Act Providing Access to Affordable, Quality, Accountable Health Care) that served as a key model for the federal Affordable Care Act (ACA/ObamaCare) signed in March 2010.  A more compelling example of states as “laboratories of democracy” is hard to find.

A lot of good material has come out in the past 24 hours: a literature review of evidence on the law’s impact from the Blue Cross Blue Shield Foundation of Massachusetts; 13 essays on the law by various Massachusetts health policy players (including yours truly) and an overview by WBUR’s Martha Bebinger; and a helpful retrospective from Health Care for All’s Brian Rosman.

Looking back over news clips and materials from April 2006, I found an arresting editorial supporting Chapter 58 written by Ed Haislmaier, a senior research fellow at the Heritage Foundation.  His article was called “The Significance of Massachusetts Health Reform.”  Here are some direct quotes:

“Some commentators, by getting wrong even the most basic facts of what the legislation actually does, have offered wildly inaccurate interpretations of the bill and its likely effects.”

“The basic insight behind a state-sponsored health-insurance clearinghouse or exchange (like the Connector) is that markets sometimes work more efficiently and effectively when there is a single place to facilitate diverse economic activity. Like a stock exchange, the health insurance Connector in the Massachusetts legislation will be a clearinghouse to match buyers and sellers efficiently and to facilitate the collection and transmission of payments, often from multiple sources.”

“The Governor and legislature have provided their citizens with the tools to achieve what the public really wants: a health system with all the familiar comforts of existing employer group coverage but with the added benefits of portability, choice, and control.”

“Other governors and legislators would be well advised to consider this basic model as a framework for health care reform in their own states.”

From today’s vantage point, it’s hard to believe this came from the Heritage Foundation, but then, maybe not so much. Heritage was founded in 1973 as a conservative alternative to the Brookings Institution and placed itself in the ideas vanguard of the 1980s Reagan revolution. Unlike other policy shops back then, Heritage proactively sought to connect conservative and libertarian thinkers with friendly members of Congress and Administrations. They nurtured ideas and sought champions for them.

In the late 1980s, they began engaging in ideas around health reform, and in 1993 positioned themselves as lead critics of the universal health legislation promoted by President Bill Clinton and his First Lady, Hillary. The Heritage alternative, championed by one of its policy experts, Stuart Butler, promoted the new idea of an individual mandate to purchase health insurance, as well as new market-based mechanisms they called health insurance exchanges.

After ClintonCare’s 1994 collapse, these ideas went on the back burner but did not disappear. Regularly promoted in reports and presentations, the individual mandate became a standard talking point for Republicans on how to achieve universal coverage.

In 2004, when Massachusetts Gov. Mitt Romney began looking to craft a Republican form of universal health insurance, Heritage gave him two core ideas, the individual mandate and the exchange, both of which found their way into Romney’s legislation, both winning approval from the overwhelmingly Democratic Senate and House of Representatives. I was executive director of Health Care for All at the time, and we were willing to experiment as long as coverage and benefits were adequate.

A spokesperson from Heritage came to Romney’s signing ceremony at Boston’s Faneuil Hall to praise the new law. Across the nation, many Republicans praised Romney’s achievement, including Newt Gingrich and then-US Sen. Jim DeMint, a South Carolina Republican, who termed it “a good conservative idea.” But when Obama came to power, things changed. In July 2009, in a widely reported national phone call with conservative activists, DeMint urged them to actively oppose Obama’s reform because: “If we’re able to stop Obama on this, it will be his Waterloo. It will break him.”

In 2013, DeMint resigned his Senate seat to become president of the Heritage Foundation. Long before then, the transformation had become complete – the ideas Heritage had championed until 2009 were now verboten. Stuart Butler, the gentle British ex-pat who nobly championed the individual mandate for years as director of Heritage’s Center for Policy Innovation, left Heritage in 2014 for, of all places, the Brookings Institution.

There was a time, less than 10 years ago, when ideas mattered to both sides of the ideological spectrum on health reform. Not today – for ObamaCare haters, it’s about positioning and political advantage.

Meet the Author

If you want to understand this transformation, please read Jane Mayer’s new book, Dark Money.  Chapter 7 is all about the financing of the ObamaCare resistance movement – I’ll offer an overview of it shortly in an upcoming column.

Meanwhile, happy anniversary to Chapter 58.  It’s holding up well and it’s a noble credit to Massachusetts.

John McDonough is a professor of practice at the Harvard TH Chan School of Public Health.  He blogs at