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Q&A: Mass. system progresses


As executive director of the Commonwealth Health Insurance Connector Authority in Boston, Jon Kingsdale is responsible for implementing Massachusetts' landmark health care reform law. Enacted in 2006, the law's ambitious goal is to ensure near-universal health care coverage of state residents within a few years. Mr. Kingsdale has helped start new programs to provide subsidized coverage for the uninsured and lower-cost coverage for individuals. A longtime health plan executive and scholar, Mr. Kingsdale also has directed rulemaking on minimum acceptable health care coverage. He spoke recently to Business Insurance Editor-at-Large Jerry Geisel on a wide range of issues related to implementation of the law.

Q: A little over a year ago, then-Gov. Mitt Romney signed Massachusetts' sweeping health care reform legislation into law. How much closer is the state to achieving universal health care coverage?

A. We are a lot closer. We have launched our two main programs. One is Commonwealth Care, the subsidized health insurance program for low-income uninsured residents. To date, we have approximately 70,000 people enrolled in that program, and another 50,000 or more in the expansion of the state's Medicaid program. In terms of raw numbers, the state's best estimate was about 370,000 uninsured before reform was implemented. We've eaten into almost a third of that, which is a substantial dent.

In addition, we just launched Commonwealth Choice. That is going very well. We are getting 1,000 calls a day, and the Web site is getting over 3,000 hits a day. We are moving along very rapidly.

Q: Who are the enrollees in Commonwealth Care? Do they tend to be at the very low end of the income scale?

A. We launched Commonwealth Care in two phases. First, we had those at or below 100% of the federal poverty level, which is about $10,000 for an individual and $20,000 for a family of four. Not only was it free, but if people didn't pick a plan after they were offered an option, we felt comfortable automatically assigning them a plan. We have pretty much full penetration there. We estimate there are about 60,000 eligible at or below federal poverty level and we have 54,000 of them enrolled.

Q: What about those above the 100% poverty level?

A. We are well ahead of budget. We had projected last December that we would have about 13,000 by May 1. In fact, we have over 15,000 between 101% and 300% of the federal poverty level. We are ahead of projections, but we have a long way to go.

Q: Is there a concern that young healthier individuals will decline coverage, while those most in need of services will enroll and that will result in much higher costs to the state?

A. That is where the logic of the health care reform law kicks in. On a purely voluntary basis, when people have to pay a premium, it is no surprise to anyone in the insurance business that people who are in more need of services--those older and sicker--are the ones that tend to buy it. We certainly have seen that in the first couple of months of enrollment of those above 100% of poverty level. But, as of July 1, the mandate kicks in for universal participation. And we have taken some steps to lower the price for a couple of income groups above 100% and below 200% poverty level. Maybe, we'll get 80% of the eligible population and it will be a pretty representative sample.

Q: Commonwealth Choice, the nonsubsidized program for individuals and small employers, now is being launched. Without subsidized premiums, will a large number of people enroll?

A. The level of interest is tremendous. We are getting 1,000 calls a day. The marketing campaign we are kicking off later this month is superb. It will be communitywide. There will be lots of partnerships with civic organizations, churches, businesses, unions. Thousands of people will buy. How many thousands and when, I can't tell you. That is because the mandate is phased in. On July 1, the law says you are supposed to have insurance, but there are no penalties until the end of the year, and even then the penalties are pretty modest until you get to 2008.

In sum, we anticipate pretty steady enrollment--not a big surge for July 1. But we are budgeting for a little less than 20,000 by Jan. 1, 2008.

Q: Can you give examples of how enrollees, because they have coverage, are receiving preventive care with problems being spotted earlier rather than later?

A. Off the top of my head, there is case after case. One example is a woman in her 50s who suffered from brain seizures for many years. She didn't even know what she had. She just knew she blanked out and seemed to fell asleep from time to time. She had trouble holding a job. She enrolled in Commonwealth Care. She hooked up with a primary care physician, who referred her to get tests. Her problem was diagnosed and now she is getting back to full functionality. That is the result of having good disease management and primary care.

Q: Is that an example of the logic of this system? Because people have health insurance, they see physicians early in the game, rather than wait and then go to emergency rooms for treatment. Shouldn't it be cheaper, to say nothing of the better care that is provided, than the old system?

A. That is the primary point of getting people insured. With good disease management and primary care and access to a broad array of services, you pick up problems when they are still curable or before they become very serious and you can treat them a lot more cost-effectively. Often, hospitalization is the result of a failure to treat adequately and continuously on an ambulatory basis. So the patient is deteriorating and going into the hospital.

That said, will it be less expensive? It is a much better way to spend dollars and it is much better care. Certainly episodes will be treated much less expensively if treated earlier. But I don't want to fool anybody. Medical care is very expensive and if you provide people with a full insurance package, it will not cost you less money.

Q: What has been the attitude of the business community toward the health care reform law?

A. In developing the legislation, lawmakers kept the business community very much in the decision-making process. As a result, there is broad support within the leadership of the business community. The business leaders participated in the reform effort. So far, they have been very supportive. That is something I treasure and it is something we will do our best to retain it.

Q: Nearly 20 years ago, Massachusetts passed comprehensive reform legislation that would have imposed a significant financial penalty on employers not offering health coverage. That law never was put into effect and ultimately was repealed. Will the fate of the 2006 law be different?

A. When the legislation passed last year, it did so with virtually no dissent. The bill that passed in the late 1980s was hastily put together with a much smaller majority passage.

That is really important when you are talking about refinancing. We're probably talking about 18% of the state's gross domestic product. Given the size of that sector, you just don't want to do that by a slim majority. You want a huge majority. That is a big difference from the last time.

Q: What lessons are there for other states considering reform legislation?

A. Each state has to take the time to figure out the right solution for their circumstances. There is a broad consensus in this country that we should have universal health insurance coverage. But there are probably 50 different ways to get there. It is important for each state that is thinking of doing this to find the right formula that will work for it and hammer it out to reach a broad agreement.