Covering the Uncovered
While Washington drags its collective feet on health reform, the states are moving ahead
Vermont and Maine are also making insurance available to everyone, but people without coverage can choose to participate or not. Will an "individual mandate" like Massachusetts's work? No one knows, but policymakers agree that without one, it will be difficult to achieve universal coverage. "That's the tectonic plate that's moved in the last year and a half," says Len Nichols, director of the health policy program at the New America Foundation, a Washington think tank. So-called young invincibles often go without, figuring the cost is too great and they won't get sick anyway. Many others forgo insurance because their employer doesn't offer it, or they can't afford it. But Massachusetts's program recognizes that people who have regular health insurance are less likely to use pricy emergency room services for primary care or put off regular checkups and preventive care that helps stave off illness. California, Pennsylvania, Oregon, and Maine are all considering proposals with some version of a requirement.
Playing the odds. In Massachusetts, Ben Healey will be a test of the mandate. The 25-year-old self-employed communications and research consultant from Brookline expects to make about $55,000 this year, so he won't qualify for subsidized coverage. He'll consider managed-care plans from any of six insurance carriers, including Blue Cross Blue Shield of Massachusetts, Fallon Community Health Plan, and Harvard Pilgrim Health Care. Deductibles for the various levels of coverage range from zero to $2,000, while copayments for doctor visits run from zero to $35. For a typical 25-year-old in the most expensive eastern part of the state, the monthly premiums for basic plans that include prescription drug coverage range from $148 to $255; at age 37, the numbers are $175 to $288. Healey would like to have the security of health insurance. On the other hand, if he decides the price is too high for what he gets, all bets are off. "I guess I'd keep hoping I won't get sick," he says. "The penalties aren't persuasive."
One reason many people don't have insurance, of course, is that their bout with cancer or a heart condition has made them a bad risk. So, while it mandates coverage, Massachusetts also guarantees that no one can be denied it. (Maine, Vermont, New York, and New Jersey have similar guaranteed issue provisions, as would the California and Pennsylvania plans, if enacted.) In Massachusetts and some other states, people like Rothfarb with existing conditions can't be charged higher rates, either.
Even when rates are equalized, a sizable chunk of the population won't be able to afford them. Many state programs would provide substantial subsidies to lower-income people; Massachusetts, for example, is finalizing a plan to totally subsidize premiums for anyone whose income is 150 percent or less of the federal poverty level. It would also create an opt-out provision for a narrow group who may be too well off to qualify for subsidized coverage but are struggling too much to buy even the cheapest plan available. "We are cautiously celebratory," says Rabbi Jonah Pesner of the Greater Boston Interfaith Organization, a coalition of 50 religious institutions that has lobbied hard for affordable coverage. "For most people it's mostly affordable, with a decent exemption process so that people won't be punished if it's not."