The national health care reform bill was modeled on groundbreaking 2006 legislation in Massachusetts requiring all adults in the Commonwealth to have health insurance coverage through an individual mandate. A new article from The Milbank Quarterly, by Brandeis health policy experts, explains how Massachusetts has handled the insurance requirement since 2006 and describes the lessons policymakers have learned.

As lead author Michael Doonan, assistant professor at the Heller School at Brandeis University says, "The individual mandate is the linchpin to making health care reform work. The individual mandate forces you to define affordability, coverage limitations, and other key aspects of any successful health care reform." Doonan adds, "moving towards universal coverage makes it possible to prevent insurance companies from discriminating against people with pre-existing conditions."

Massachusetts has a head start on addressing some of the issues that will now be faced on the national level, and on a state-by-state basis. Most people still receive insurance through their employer with no changes. The previously uninsured are covered through the expansion of existing subsidized health care programs such as MassHealth (the state's Medicaid program), the Children's Health Insurance Program, and the employer-based Insurance Partnership Program. New programs, such as Commonwealth Care, were also created. Reforms also led more people to sign up for coverage at work or to purchase coverage through the new exchange, the Commonwealth Health Insurance Connector Authority.

Massachusetts enforces the insurance mandate by requiring residents to file proof of health insurance with their annual tax forms. Residents who cannot afford insurance may obtain a waiver, but most have not done so. Currently, ninety-seven percent of Massachusetts adults are covered--the highest number in the nation. The largest increase in enrollment was implemented through the Commonwealth Care program, which allows those with a family income under the 300 percent federal poverty level to receive subsidized insurance. The Massachusetts mandate also limits the ability of insurers to exclude pre-existing conditions from coverage.

Doonan says, "While Massachusetts, like the rest of the country, still has problems with rising health care costs, this program greatly expanded coverage and access to health care services. The program also reduces the fear that insurances companies will drop coverage as soon as you get sick." The program enjoys strong public support in part because of ongoing stakeholder engagement including consumers, hospitals, insurers, the business community, and others.

Now that legislation at the national level has passed, the critical implementation stage begins, and how this is handled will determine the long-term fate of health care reform in the United States. Critical lessons can be learned from the Massachusetts experiment. The article is based on a case study using interviews with key stakeholders, state government representatives, and officials from the Commonwealth Health Insurance Connector Authority.

Note: If no author is given, the source is cited instead.

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