| The Massachesettes bill aims to cover 95 percent of the state’s uninsured residents within the next three years. |
The legislation will cover the state’s approximately 550,000 uninsured people, which represents 11 percent of the population. Most of these people fall into one of four categories: low income individuals, part-time employees, single adults without children, and youngsters just starting out in the labor force. The impact of these patients is felt disproportionately in urban medical centers such as Boston Medical Center, which now will face the challenge of transitioning from free care plans to subsidized insurance premiums.
The legislation can be considered an evolution of the current system. Much of the old structure, including federal Medicaid funding, remains as a backbone.
The ideology of the proposed system is summed up by the phrase “everyone plays their part.” Ideally, individuals, the government, healthcare providers and employers will all work together to promote cost-effective, quality care.
A number of strategies will be employed to improve coverage. The foremost of these is the introduction of the Commonwealth Health Insurance Connector, which is a mechanism to make it easier for employees find affordable health insurance. Employees can combine employer contributions and even keep policies through job changes. To add more incentive, the Connector allows people to buy insurance with pretax dollars.
For those without adequate funds to take advantage of the Connector, a number of subsidies will buttress coverage. The Commonwealth Care Health Insurance Program supplies subsidies on a sliding-scale basis for individuals with incomes below 300 percent of the federal poverty guidelines, roughly $48,000 for a family of three. There will be no premiums for persons with incomes below 100 percent of the guidelines and no deductibles.
As of July 1, 2007, all state residents 18 years of age and older must have some minimum level of health insurance. The Connector will determine who can or cannot afford insurance. Those who fail to obtain coverage will be penalized. A notable penalty is the loss of personal exemption for the 2007 tax year and in subsequent tax years a fine equaling 50 percent of the monthly cost of health insurance for each month without insurance. These measures enforce what is being touted as the Individual Mandate, of which the central hypothesis is that healthy people in the same risk pool as sick people will stabilize the cost for everyone.
Hospitals and community health centers will receive new grants to target support for certain populations. Coupled with this are reforms for uncompensated care. The current pool will be terminated as of Oct. 1, 2007. In its stead, the Medicaid-administered Safety Net Care fund will reimburse uncompensated care based on standard fee schedules. The fund represents the redeployment of money spent on institutions to that spent on coverage of individuals.
The last piece of the legislation is the contribution of employers. The reform’s Fair Share Contribution provision necessitates that as of Jan. 1, 2007, all employers with 11 or more workers must adopt a “cafeteria plan” as defined by federal law, whichallows workers’ purchase of healthcare with pretax dollars. These plans must be filed with the Connector. Employers must endeavor to provide a “fair and reasonable” contribution, or they are required to funnel into the “fair share” program, which commits employers to pay up to $295 per full-time-equivalent employee, per year.
There are penalties for employers that do not participate. A “free-rider” surcharge will be assessed on employers whose employees use free care more than five times per year in aggregate or if one employee uses free care more than three times in one year. The Division of Health Care Finance and Policy will enforce the surcharges as “greater than 10 percent, but no greater than 100 percent of the cost to the state” of the free care.
It is difficult to anticipate how this health system will look three to five years from now or what impact the legislation will have on neurosurgeons. The reform is pro-consumer and blends existing plans with newer products and services. Private health insurance and medical care delivery and reimbursement will remain untouched as will sustainable growth rare measures.
Massachusetts with its reputation of progressive legislation and medical excellence serves as a worthy petri dish for a health plan that tries to provide health insurance for all.
Lawrence S. Chin, MD, is chair of the Department of Neurosurgery at Boston University School of Medicine and chair of the AANS Young Neurosurgeons Committee. Akshal Patel is a medical student at Boston University.