Anthony Wright is executive director of Health Access California, the statewide health care consumer advocacy coalition. He blogs daily at the Health Access WeBlog and is a regular contributor to the Treatment.

The vibrant discussion on the Massachusetts reform by Jon Cohn, Diane Archer, and Jonathan Gruber is obscured because the debate is mixing up two different questions: Is the Massachusetts reform succeeding? And is Massachusetts a model for national reform?

Having not lived in the Bay State since college, I'll refrain from the first question, even though I've written extensively about the Massachusetts law. Even Massachusetts-based supporters of the law would argue that it is a work in progress, along with pointing out the progress has been made in reducing the number of uninsured.

The missing context in the debate is that Massachusetts started from a far different place than the country as a whole:

  • Massachusetts was already in the top ten of states with the lowest uninsured rate. (Now it's tied with Hawaii with the lowest uninsured rate.)

  • Massachusetts has an employment market with a lot of higher-wage workers, and an overall high rate of employers offering coverage to their workers.

  • Massachusetts has traditionally funded its health care safety-net system more generously than most, which allowed the health reform to be funded largely through redistributing funding within the system, rather than raising significant new revenue.

  • Massachusetts had a much more robust regulation of insurers--which in MA are all nonprofit--that many other states. Massachusetts was already one of five states requiring "guaranteed issue," where people could get coverage regardless of pre-existing conditions.  

Whatever you think of the Massachusetts' "Chapter 58," the nation's needs dictate a policy solution that bigger and bolder, and just simply different.

When California policymakers-as in Massachusetts, a Republican Governor and Democratic Legislature-looked at health reform last year, they found that, as described in this Health Access report, they needed to go significantly beyond the Massachusetts plan, for policy and political reasons. California has one of the lowest rates of health insurance and of employers offering insurance; has one of the worst rates of per-patient Medicaid spending; and has a "wild west" of an individual insurance market.

The California proposal included significant public program expansions and these elements that went beyond Massachusetts: subsidies up to and above four times the poverty level; significant new insurance market reforms and rules on insurers; a meaningful employer contribution requirement to shore up on-the-job benefits; an option to get coverage through a public purchasing pool and public health insurance options; and the raising of significant new revenues to pay for the expansion.

That said, California's effort stalled, partially due to obstacles unique to our state (an unparalleled budget crisis, a requirement to pass revenues with a 2/3 vote in the legislature that make 60 votes in the U.S. Senate look easy, etc.), and because some argued, with some merit, that it needed to go even farther. For national reformers, I've argued previously that the up-and-running Healthy San Francisco offers a more relevant model than Massachusetts to look at, although SF has some unique characteristics as well.

So Gruber and Cohn are right that the big lesson from Massachusetts is not any specific policy component, but that health reform and coverage expansions are possible; Archer is right in her policy recommendations of what is needed in a federal reform, including the public health coverage option. Some of that is based on the needs of the nation, which face a different set of challenges that what Massachusetts did. So let's not get distracted in refighting past battles in Massachusetts when there's a far more significant fight brewing over the future of federal reform.

--Anthony Wright