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From Boston, a Lesson About Obamacare

Getty Images: Elsa

President Obama was in Boston on Wednesday—not to watch a baseball game, but to send a message about health care reform: The idea really works. Given all the news about Obamacare lately, it’s a message the country very much needs to hear. The template for the Affordable Care Act is the reforms that Massachusetts officials enacted in 2006. While the introduction of that scheme was not entirely smooth and enrollment was very slow at first, people signed up eventually and, today, 97 percent of residents have coverage. Studies, by the Urban Institute, suggest access has improved and financial barriers to care have diminished moderately. The scheme is far from perfect, but it's hard to take issue with the statement Obama made on Wednesday: “Health care reform in this state was a success.”

But will it be a success in the rest of the country? One key factor has less to do with the letter of the law than it does with the people implementing it—and, in some cases, trying to undermine it. Here the timing of the visit, on a day the Red Sox would go on to win the World Series, was particularly apt. As almost everybody knows by now, the Red Sox organization promoted the Massachusetts health reforms, sponsoring efforts to enroll people and even having players appear in ads directly addressing the young, healthy people who might think insurance was unnecessary. As I wrote a few months ago, discussing the Red Sox partnership:

the Red Sox aren’t the only, or even the primary, reason Massachusetts had so much success getting people—even young and healthy ones facing some form of “rate shock”—to sign up for insurance. Rather, it was part of a broader campaign that involved a lot of direct outreach through intermediaries, like churches, universities, and unions, as well as employers and the health care industry. … In Massachusetts, political, business, and health care leaders were united behind the plan. It may not have been their idea of what health care reform should look like, but they understood the value—human as well as financial—of getting people to sign up for health insurance once it was finally available.

That spirit still exists today, all across the country, although you might not have noticed. Leaders of the health care industry have been generally supportive of reform—and, for the most part, adapting to it rather than trying to undermine it. You can see this clearly in the hospital industry, which rather than screaming publicly about payment changes in Medicare is quietly reinventing itself in ways that will, hopefully, make health care efficient. You also see it with the insurance industry, which rather than use website problems to endorse repeal has instead been lending the federal government technical assistance to get things working. Like everybody else in the health care business, these groups have plenty of financial incentive for playing nice. More people insured means more people paying bills. But that’s what happened in Massachusetts, too—everybody in the health care business saw the upside of helping to make reform work, rather than trying to tear it down.

That attitude has not prevailed in politics, obviously. At both the state and national level, Republicans have been at best indifferent and at worst hostile to implementation of the law—in some cases, openly wishing for its failure and urging potential partners with or surrogates for the federal government not to help enrollment. This hasn't made it impossible for officials to implement the law, nor does it excuse poor management of Obamacare's website development. But Republican resistance has certainly made implementation more difficult. It's also meant millions of low-income Americans aren't getting health insurance, thanks to Republican officials successfully blocking states from expanding their Medicaid programs as the law envisioned.

Republicans and their allies would claim the problem here is Obama, the Democrats and his supporters, for pushing through a law that had no Republican support in Congress. But who’s fault is that? In 2009, Obama and legislative partners like Senate Finance Chairman Max Baucus made all kinds of efforts to accommodate Republicans—remember the Gang of Six?—only to be spurned by Senators Mike Enzi, Charles Grassley, and eventually (on the final votes on the bill) Olympia Snowe. More important, the general idea of a regulated, private insurance market with subsidies and a mandate to purchase had a long conservative pedigree, going back to the days when the scholar Stuart Butler endorsed such a model at the Heritage Foundation. That’s one reason it attracted the interest and enthusiastic endorsement of Mitt Romney, the Republican governor who helped craft and then signed the Massachusetts reforms into law. Whatever genuine reservations conservatives might have about the way Obamacare eventually turned out, those differences can't possibly explain the depth and intensity of hostility nearly all Republicans show today.

The bipartisanship of the Massachusetts effort was on display seven years ago, when Romney signed the bill and appeared at historic Faneuil Hall—alongside the late Senator Edward Kennedy, the longtime champion of universal health care who had worked closely with Romney to make the Massachusetts reforms possible. Obama spoke in the very same spot on Wednesday, but he had no Republican partner. That's not good for reform and that's not good for the country. Decide for yourself who bears responsiblity.