On April 12 Massachusetts' Republican
governor Mitt Romney signed a sweeping reform bill that
will extend health insurance coverage to nearly all
citizens of his state. But don't confuse the scheme
with Canadian healthcare. It's still a very private
system, but now all citizens who can afford it must
make sure they're covered — just like car insurance
— and those who can't will get their care subsidized
by the government. Could this free-market yet universal
model of care hint at what's to come in Canada when
the dust settles on the Chaoulli case?
Not a chance, says Ted Marmor,
PhD, a professor of public policy at Yale University
and an expert witness for the Quebec government in the
Chaoulli Supreme Court case. "The Massachusetts experiment
has almost nothing to do with fundamental reform and
it has everything to do with what Canadians take for
granted — which is coverage for catastrophic health
insurance."
"We're at the starting point, not
the end point. There's nothing for Canadians to learn
from Massachusetts, but there is a lot for Massachusetts
to learn from Canada," adds Dr Marmor.
HOW
IT HAPPENED
Even if Dr Marmor isn't overwhelmingly enthusiastic
about its details, he does support the bill on the whole
as a gradualist step in the right direction. Antonia
Maioni, PhD, director of the McGill Institute for the
Study of Canada, says lawmakers had to keep the main
thrust of healthcare market-oriented, otherwise the
reforms would have scared everyone off. "On the surface
it's really surprising that it's coming from a Republican
governor, but the Massachusetts bill is fairly conservative.
It's really about people taking responsibility for their
own healthcare," she says. "In order to get closer to
universal coverage lawmakers had to break the log jam
between the status quo and single payer."
And there was another reality that
made this reform something a conservative could support
— the state already had to pay for a lot of these
people anyway. The uninsured would still get treated
if they were sick, and if they couldn't pay the state
would often have to foot the bill.
And what of this car insurance
comparison? "Switzerland is the only precedent I see
in the industrialized world that has mandatory health
insurance for those who can afford it," Dr Maioni explains.
DEVIL
IN THE DETAILS
One thing everyone can agree on is that the bill is
mind-numbingly complex. Kate Nordahl, Director of Policy
and Research for the non-profit Blue Cross and Blue
Shield Foundation of Massachussetts, tries her best
to simplify its most important details. "It merges two
types of insurance markets — we in the States currently
have separate insurance markets for small businesses
of up to 50 people and for individuals — this bill
merges these two markets to achieve certain economies
of scale and savings," she says. "And for the unemployed
and working poor there's a portion of the bill that
sets up something called Commonwealth Care which gives
subsidized insurance for people who make up to 300%
of the federal poverty level [roughly $35,000Cdn] or
less. It's a sliding scale — if the person just
hits the poverty level or makes less, their insurance
will be fully subsidized."
WHAT'S
UP DOCS?
The best news for physicians in the plan hasn't been
publicized much. "It includes mandates to raise the
rates that Medicaid [the state-funded plan for the poor]
pays to both hospitals and physicians," says Ms Nordahl.
"There's been discussion about how the rates Medicaid
pays are much lower than other insurers — and are
lower than the costs doctors incur treating people.
About 15% of the total pool of money in this bill goes
to physician rate increases for Medicaid."
Dr Maioni says this detail is crucial.
"Medicaid patients have a hard time finding a physician,"
she notes.
What's more, having (nearly) everyone
covered lessens the chance of an MD getting stuck with
a rubber cheque from an uninsured patient.
But things aren't all rosy for
doctors under the Massachusetts plan. "There's a component
that allows the insurer to have 'selective provider
networks' more than had been the case before," note
Ms Nordahl. "There are specific provisions that say
insurers can develop a network that only includes a
subset of physicians. This would limit a patient's choice
of doctors."
"In one sense this makes Massachusetts
a better place to practise medicine," says Dr Marmor.
"You as a doctor wouldn't have to imagine that giving
care to a patient would involve the possibility of their
being bankrupted. I think it makes Massachusetts a somewhat
more attractive place than it would be otherwise for
a Canadian doctor who's been offered a post in the state."
SLIPPERY
SLOPE?
Ms Nordahl is curious about the bill's future impact.
"It will be very interesting to see how it will work
out," she says. "The big question is whether or not
affordable insurance products can be developed —
and whether they'll stay affordable over time or will
there be more annual premium hikes of 13-14% like we've
seen in recent years."
Dr Marmor wonders if Americans
will start demanding universal coverage. "The significance
of this health bill is that it will prompt other states
to wonder if they should jump on the bandwagon —
like what happened in Canada during the 1950 and 60s
where, starting with Saskatchewan, one province after
another dealt with healthcare."
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