by Tom Walsh

Unlike many thorny public issues, providing universal access to affordable, high-quality medical care for all Massachusetts citizens enjoys the support of nearly everyone. How to get there, however, remains a very open question.

Despite the fact that the Bay State is one of the best when it comes to health coverage, somewhere between 450,000 and 600,000 Massachusetts citizens are not insured and do not have easy access to health care. "It is unconscionable that people remain uninsured in our state," Alan C. Woodward, M.D., MMS president, told the Society's House of Delegates at its Interim Meeting in November. His remark was greeted with enthusiastic applause.

Proposals Are Percolating
Just before Thanksgiving, Gov. Mitt Romney unveiled his plan. Health Care For All, a prominent advocacy group, has a plan that differs significantly from the governor's. The Blue Cross Blue Shield of Massachusetts (BCBSMA) Foundation expects to unveil a plan this spring, and in November it contributed a major cost-benefit study of the issue.

Hovering over all of this is a proposed amendment to the state constitution that would require the Legislature to devise a plan for universal health coverage. And just before Vital Signs went to press, state Sen. Richard Moore (D-Uxbridge) and Rep. Deborah Blumer (D-Framingham) introduced a bill that seeks to extend both employer-provided and state-funded coverage.

MMS Supports Universal Access
The Massachusetts Medical Society stands firmly behind the goal to provide everyone in the state with universal access to appropriate medical care. Moreover, MMS leaders will position the state's physicians, the key deliverers of care, at the heart of debate over how to make it happen. "The doctors have to be at the table," concurred Ron Preston, Massachusetts Secretary of Health and Human Services.

Remaining questions are many, however. Will the program be based on private insurance, a single-payer government plan, or some hybrid? Will employers be mandated to provide health insurance, or will they instead receive strong incentives to cover their workers? Will universal access cost taxpayers substantially more money? And will the final plan need the muscle of a state constitutional amendment to ensure implementation?

Jack Evjy, M.D., MMS past president, chairs an MMS task force charged with sorting through these issues. "We have a very specific destination, but not a predetermined way to get there," Dr. Evjy said. "Whatever plan emerges must address cost, quality, and access," added Ken Peelle, M.D., MMS vice president and task force vice chairman. "If you try to address one without the other two, you're going to lose."

A New Flurry of Activity
In July, the Legislature approved a proposed constitutional amendment to require lawmakers to find a way to achieve universal health coverage. However, the proposal does not specify how this should be done, and the Legislature must approve it a second time before it appears on a statewide ballot for voters in 2006.

This fall brought with it more universal-access activity. In late November, the BCBSMA Foundation, as part of its "Roadmap to Coverage" program, released the results of an Urban Institute study it commissioned. Among the findings are the following:

• Hospitals, community health centers, and physicians provided $1.1 billion in medical care to uninsured patients in Massachusetts in fiscal 2004.
• Covering the uninsured in the state would cost between $374 million and $539 million annually.
• Improved health from expanded coverage to the uninsured could result in economic and social benefits ranging from $1.2 billion to $1.7 billion.

"We will continue to try to inform the debate with solid, credible, independent data," pledged Andrew Dreyfus, Foundation president.

Romney Plan Unveiled Early
Perhaps spurred by state Democratic leaders' promises to make health care the showcase issue in 2005, Republican Gov. Romney began to unveil his plans to extend access to care via an opinion article published in The Boston Globe the Sunday before Thanksgiving. Highlights of his plan are as follows:

• Provide less expensive -- and lower-benefit -- coverage to workers in small businesses and to self-employed workers who don't buy health insurance now because of its cost. The Romney plan would use incentives to encourage everyone to buy at least minimal insurance.
• Extend the duration of coverage the state now provides for unemployed people.
• Make concerted efforts to sign up all who are eligible for Medicaid.
• Cover those who remain uninsured under a program that would direct them to more cost-effective medical treatment.

The governor's article touched off a vigorous debate on the issue in the news media and elsewhere. "This is not like instant coffee where you put the powder in the cup and there it is," Sec. Preston told Vital Signs. He said the governor wants people to have choices and that a successful program will likely take several years to complete.

John E. McDonough, executive director of Health Care For All, the prominent advocacy group, warned in an essay late in November, "Experience teaches that proposals offering big returns for free are too good to be true… The notion that we can redirect existing resources without new public outlays and/or contributions from employers who don't provide insurance has been proven wrong time after time. If it were cheaper to cover the uninsured with existing dollars, we would have done it long ago."

In early December, the MMS joined Health Care For All and various other health care stakeholders to form the Massachusetts Health Care Reform Campaign, another collaborative push for universal access.

MMS Task Force Will Stay Focused
Dr. Evjy emphasized the importance of staying focused and pledged that the MMS task force will do just that. "This effort is not necessarily about transforming the whole health care system," Dr. Evjy said. "Our charge is to focus on the uninsured and to reduce their number as much as possible, preferably to zero, one way or another."

Dr. Evjy also said the task force will be open to various ideas. That was good news for John Goodson, M.D., the Newton internist who heads a group promoting the constitutional amendment. "The amendment commands everyone to step forward and address the enormous complexity of this issue," Dr. Goodson explained. "My end game is to have a serious, directed, effective stakeholder process with a real commitment to reach closure."

The task force's professed open-mindedness was also good news for Pat Downs, M.D., a retired internist who has been a strong voice within the MMS for a single-payer solution. "To my mind, the only logical solution is single-payer," she said. "It provides universal care by definition. Everyone is covered, period."

While much about universal access remains to be decided, it's clear that reform is in the wind in Massachusetts. "We have to stay allied with data and critical thinking," Dr. Evjy said of the MMS's pivotal role. Dr. Peelle concluded, "Expanding the number of people with health insurance is a benefit to those who are uninsured and to the system as a whole. Therefore, we would support reasonable proposals that aim for that goal."