It’s been a few months since President Barack Obama decided to tie up Boston traffic by giving a health care speech right before Game 6 of the World Series. But the Massachusetts health care law, signed by Obama’s 2012 Republican challenger Mitt Romney, is still held up as proof of Obamacare’s inevitable triumph.
Just last week The New Republic trotted out Jonathan Gruber, the MIT professor who was a consultant for both Romneycare and Obamacare, to defend the federal law. Groups like Generation Progress emphasize Romneycare’s success with milennials. And it’s frequently pointed out that Romneycare enrollment started slow, not least by the president himself.
“[A]ll the parade of horribles, the worst predictions about health care reform in Massachusetts never came true,” Obama said in Boston in October. “They’re the same arguments that you’re hearing now.”
Before concluding those arguments are necessarily wrong, it’s worth considering a few things.
1.) Massachusetts had a relatively small uninsured population before Romneycare. According to the National Health Insurance Survey in 2006, the percentage of Massachusetts residents who lacked health insurance was a little more than half the national percentage and already the lowest rate in the country before Romneycare.
In the two years before Romneycare’s individual mandate to purchase health insurance took effect, less than 10 percent of the commonwealth was uninsured, according to the Kaiser Family Foundation. That number dipped below 5 percent in the two years after Romneycare implementation.
As conservative columnist Terence Jeffrey observed in 2011, Romney “took a state where nine out of 10 people had health care coverage and turned it into a state where 9.5 out of 10 people had health care coverage.” Whatever other virtues or flaws Romneycare has compared to Obamacare, the Bay State was already much closer to universal coverage than the rest of the country.
2.) Massachusetts had already wrecked its individual health insurance market before Romneycare. One of the big concerns about Obamacare after the flood of cancellation notices for non-compliant insurance policies is its impact on the existing individual health insurance market. In Massachusetts, that ship had already sailed.
Massachusetts Gov. Michael Dukakis tried to achieve universal coverage through a 1988 plan that forced employers to cover their workers. It was repealed. His Republican successor Bill Weld signed a law that created guaranteed issue, a requirement that individual insurers cover everyone regardless of preexisting conditions, and community rating, which forced them to charge young and old people essentially the same rates.
People waited until they needed health care to buy insurance. Premiums went up on those who stayed insured. Emergency rooms became crowded. The company eHealthinsurance fled the state. Romneycare tried, with varying degrees of success, to fix some of these problems.
But unlike Obamacare, Romneycare was imposed on an individual insurance market that was almost entirely dysfunctional. Free-market health policy expert Avik Roy later estimated, “If 10 is a libertarian utopia, and 1 is a left-wing dystopia, Governor Romney moved Massachusetts’ individual health-insurance market from a 2 to a 4.”
3.) Obamacare isn’t working well in Massachusetts. Massachusetts already had experience with exchanges and the basic architecture of Obamacare, so you would think it would be an early Affordable Care Act success story. You would think wrong. Massachusetts has enrolled just 8,00o people in its Obamacare exchange through the end of January, out of an original target of 155,000.
The Obama administration had to grant Massachusetts a three-month extension to get its exchange website working properly — only half the extension the commonwealth requested — and wade through a backlog of 50,000 paper applications. The head of the Massachusetts Health Connector broke down in tears while describing the exchange’s handiwork.
“These people came here to lead and innovate, and instead they’re doing manual workarounds, and they are embarrassed to tell friends and family that they work for the Health Connector,” Jean Yang wept.
4.) Romneycare had lots of problems too. Unlike Obamacare, Romneycare polls well and is a bipartisan achievement. But Massachusetts also has the highest health insurance premiums in the country. That problem could get worse amidst reports that 60 percent of the commonwealth’s small businesses may experience rate hikes of up to 97 percent.
Emergency room visits actually grew in Massachusetts after the law past, counter to hopes they would decline. (Though the Blue Cross Blue Shield Foundation did find the first drop in Massachusetts ER visits in early 2012.) Massachusetts patients experience long wait times for primary care physicians and the Massachusetts Medical Society found last year that at least half of primary care practices are closed to new patients. Boston has the longest doctor wait times in the country, including 72 days to see a dermatologist and 66 days to see family doctor. This compares to an average wait time in 15 major metropolitan areas of 18.5 days.
5.) The myth behind the mandates. The individual mandates for both Obamacare and Romneycare were largely sold as eliminating free riders and making people pay for their health care. Romney was particularly fond of this argument. “Everyone has a requirement to either buy [health insurance] or pay the state for the cost of providing them free care,” he said in a Republican presidential primary debate. “Because the idea of people getting something for free when they could afford to care for themselves is something that we decided in our state was not a good idea.”
But in both cases, the individual mandate is actually intended mainly to counteract the effect of making insurers cover people regardless of preexisting conditions. Making the young and healthy buy insurance subsidizes insurance companies taking risks on the old and sick. Romneycare ended up reducing uncompensated care by much less than it increased state health care spending. Obamacare is targeting a much larger population.
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