News & Events

Lessons from the health care rollout

By Jon Kingsdale  |  May 3, 2010
IMPLEMENTING NATIONAL health care reform could pose the greatest domestic policy challenge since executing the Civil Rights Acts of the 1960s.

National health insurance has been a long time coming — nearly a century. This past year of highly partisan health care debates has exhausted Congress and the nation.
Now what?

A whole lot of work, of course — hundreds of new, complex federal regulations to be drafted, lobbied, and revised; nearly 50 state exchanges to be set up; and explaining the many complexities of new insurance options and requirements to millions of employers and hundreds of millions of citizens anxious to know how they are affected.

All this in the face of heated resistance from many angry Americans and nearly the entire Republican Party. Efforts to outlaw the “individual mandate’’ are now proceeding in dozens of states, cast in the emotional rhetoric of personal freedom and states’ rights.
Most Americans are still confused about this reform. As with last summer’s debate about “death panels,’’ fears are easily stirred. Like politics, all medicine is local and personal. Implementing reform across this diverse country will require sensitivity to local realities. It also depends on the cooperation and varied capabilities of 50 state governments. The law will take nearly four years to put into effect and years more to assess, adjust, and evaluate.

All the while, public support must be built and sustained. While not freighted with the emotions of civil rights, the arcane technicalities of health financing are far more impenetrable than the moral imperatives of racial equality. And the level of trust in government has never been lower.
Even liberal Massachusetts saw its first effort at universal coverage, enacted in 1987, stymied and then repealed. Massachusetts implemented a very different approach in 2006. Proponents and opponents of national reform have assessed our model, ad nauseam, as a proxy in the national debate.

Four years after enactment, Massachusetts has learned about the challenges of implementing near-universal coverage. Here are a few lessons:

1. It’s a campaign: In any successful campaign, continuous progress must be demonstrated and broadly communicated. In Massachusetts, we built partnerships with private and public groups, so that people heard and read about the law everywhere — at Fenway Park, in church, while shopping, or riding the subway. We launched this effort with the Red Sox, and held more than 300 educational forums across the state, the equivalent on a national scale of 15,000 outreach meetings. As a result, voter support for reform has remained high, ranging from 59 percent to 75 percent.

2. Adequate resources: The Massachusetts Legislature appropriately funded implementation with $35 million in the first year; the equivalent on a national scale would be $1.65 billion. Never were shortages of time, expertise, or resources allowed to stand in the way of meeting legislated deadlines.

3. Coordination: Somebody has to be on point to drive implementation across federal agencies and the other organizations needed to execute this undertaking. The Health Connector used multiple consultants and outsourcing strategies, while staffing up, to meet deadlines. With 50 states and far broader legislation, the federal effort will require a Herculean coordination effort.

4. Experiment and evaluate: This effort is new and not everything will go as planned. For example, running an exchange means offering customers what they want to buy, but that’s neither obvious nor unchanging. Massachusetts’ exchange is a learning organization. Key initiatives were launched as pilots, and we have not been afraid to revise them and try again.

5. Transparency: The biggest challenge Washington faces in “helping’’ Americans gain access to care is their distrust of government. Transparency is the antidote: making tough decisions in public; meeting endlessly with employers, unions, insurers, clinicians, and citizens; and both talking and listening out there, in at least 15,000 communities. These are essential to building trust.

6. Harness the market: State exchanges are essentially stores that sell insurance, combining government’s responsibility to protect consumers with a retailer’s need to serve customers. Brow-beating various industries may be good partisan politics, but the Health Connector has worked diligently at creating solid, long-term working relationships.
The Red Sox lent our campaign a reservoir of nonpartisan good will. The campaign worked: more than 97 percent of Massachusetts residents are insured, the individual mandate has been accepted, and bipartisan support remains strong.
Congress and the president have labored mightily to bring forth national reform, modeled after Massachusetts. Now the executive branch has 3 1/2 years to work with 50 very different states in bolstering popular support and executing effectively. That will require massive amounts of technical expertise and project management, combined with public outreach and creative communications.

The real campaign has just begun.

Jon Kingsdale is executive director of the Massachusetts Health Connector.