On the ninth floor of an office building just off the Boston Common, a group called Health Care for All runs a help line that, not long ago, got 40 calls a month. Today, the calls each month have swelled to 3,000, as people throughout Massachusetts phone in for guidance in navigating a state experiment in health reform that is the most ambitious in the country -- and a test of Sen. Barack Obama's vision for reshaping health care nationwide.
Kate Bicego, the help line's manager, slipped on her headset one recent afternoon as a call came in from Travis Lynn, a 26-year-old from Jamaica Plain with asthma and a part-time job at an old movie theater. He wanted to renew his enrollment in Commonwealth Care, government insurance that Massachusetts now offers adults who cannot get coverage through their work or afford it themselves. After a few questions, Bicego told him: "So, it sounds like you will still be eligible . . . premium-free, with vision, dental and medical."
Lynn is one of 439,000 people here who have gained insurance since Massachusetts embarked two years ago on a path to near-universal coverage. More than half of them are paying toward it; the rest, like Lynn, get it free. How close Massachusetts can come to its goal -- and what obstacles it encounters -- is significant, because its strategies resemble much of the approach to health care that Obama has said he would pursue if elected president next week.
Obama says he would keep the familiar arrangement in which most Americans get health insurance through their jobs, as Massachusetts is doing. Yet he also favors profound -- and controversial -- changes that Massachusetts also is putting in place: Expanding government insurance programs and subsidies. Requiring employers to offer their workers coverage or face penalties if they do not. Forbidding insurance companies to reject anyone or charging more if they are sick. Creating a national health insurance exchange to help people to find and compare private insurance policies on their own.
In the most significant departure from the Democratic nominee's thinking, Massachusetts has imposed a mandate that requires most adults to carry health insurance -- and fines them if they refuse.
In the 31 months since the experiment here began, the share of working-age people without health insurance has plunged -- from 13 percent to 7 percent by one estimate -- more sharply and quickly than anyone expected, leaving Massachusetts with the lowest uninsured rate in the country. But the unexpected number of people also has translated into higher-than-expected costs. Massachusetts has been forced twice to scrounge for extra money, totaling more than $250 million this year and last, from state funds and other places.
There have been more unintended consequences. The large number of people who have gotten insurance and are suddenly looking for care has aggravated a shortage of family physicians and other primary-care doctors. A reshuffling of federal and state money, to help pay for the extra insurance, has pulled funds away from some hospitals and clinics that have long been havens for poor patients.
Hard as it was to enact Chapter 58, as the health-care law here is known, the work of putting the plan into practice is proving even more rigorous, according to state officials, business leaders, health-care providers and community activists. The law left unanswered polarizing questions, including who should be eligible for subsidies, what benefits must be included and whether some people should be excluded from the mandate.
"It isn't like you come up with a perfect plan and turn it on and see how it works," said Brian Rosman, research director at Health Care for All, the nonprofit that runs the state's largest private health help line. "Washington needs to understand that as well."
"This is all really a journey," said Nancy Turnbull, an associate dean at the Harvard School of Public Health and member of the governing board of the Health Connector, a new agency created out of the law. "Every time we make one of these decisions, we take a leap of faith."
Whether what is unfolding in Massachusetts could be replicated in Washington during an Obama administration is, people here say, an open question. The law that emerged in 2006 from the gold-domed statehouse on Beacon Hill was the product of an unusual alignment of outside forces, motivations of key players, and the local health-care climate.
Massachusetts's lawmakers had been warned that federal health officials would take away $385 million a year in money for poor patients unless the commonwealth found a different way to spend it. And on the streets of Boston, an influential coalition -- community activists, hospitals, doctors, unions and hundreds of religious groups -- had gathered signatures for a popular ballot initiative that, if the legislature did not act, could have rewritten the state constitution to make health care a right.
Then-Gov. Mitt Romney, a Republican on the cusp of his own presidential campaign, was calling for a "culture of insurance" as he sought tangible accomplishments. At the same time, Massachusetts faced a smaller challenge than much of the country, with fewer uninsured residents to start with and fewer undocumented immigrants, who cannot qualify for help.
Even under such favorable circumstances, Chapter 58 was stalled in the legislature for months, as businesses balked at the prospect of penalties for not insuring their workers. That fractiousness was still in view the April 2006 day that Romney staged a theatrical bill-signing in historic Faneuil Hall; he vetoed that part of the law, although lawmakers later restored it.
The Health Connector -- similar to the health exchange Obama envisions to help people shop for private health plans or a new public one -- was created to run the new programs and shepherd the reforms. One of its first tasks was to spread the word that Massachusetts now required insurance. It set up a booth at Boston's beloved Fenway Park. Banks, supermarkets, buses, cable television and grass-roots groups chipped in. Buying health insurance "is a grudge buy," said Jon Kingsdale, the Connector's executive director, "that has to be actively sold."
The sales pitch worked better than imagined, because the state had underestimated how many people were uninsured. After the first year, 176,000 people -- 40,000 more than predicted -- had rushed into Commonwealth Care, the program Lynn joined that provides free coverage or subsidies.
Even now, some residents go without health insurance. Some are offered coverage through their jobs but cannot afford it. The law does not allow subsidies for them. In fact, the Connector board agreed to exempt from the mandate about 60,000 people, some in that group and others with incomes too high for Commonwealth Care but too low for private insurance.
The effect of requiring insurance, the biggest difference from Obama's plan, is a matter of debate. Neera Tanden, his campaign's director of domestic policy, said of his plan, "With a mandate or without a mandate, we are dramatically expanding coverage."
Here in Boston, the common wisdom is different. "The mandate has been an overwhelming influence," Kingsdale said. The price of refusing to get insurance is climbing: from a $219 tax penalty for 2007 to as much as $900 this year.
Last year, MabelSarah Lubogo, 43, a certified nurse's aide who rents a one-bedroom basement apartment in Belmont, paid the $219, figuring it was less than the price of insurance. She used to get coverage through an office job. When she switched work four years ago, she looked for a policy by herself but found them too expensive. Last year, she went to a hospital emergency room twice with unexplained fevers -- leaving her with $4,000 in bills she still is paying off.
This year, a letter arrived from the state saying Lubogo would be fined $75 a month if she didn't get insurance. She called a phone number she saw on television and signed up for a Commonwealth Care plan that costs her $167 a month. With fibroids that need treatment, she said, "I'd rather have something to help me along."
Across Massachusetts, there has been little hint of backlash against the requirement. Public support for the law, high when it passed, has risen since then, surveys show.
The mandate on individuals appears to be having a greater effect than the pressure on companies. "Fair share" fees that businesses must pay if they do not offer coverage are substantially smaller than the cost of helping workers with insurance premiums. The proportion of Massachusetts companies providing insurance, higher than in many states, has barely changed.
The largest lingering question here is whether Massachusetts, having already made big strides in insuring people, can solve the more intractable problem of health-care costs. Chapter 58 "didn't do anything with cost containment," said Massachusetts Senate President Therese Murray (D). "We can't sustain the costs the way they are."
This year, Murray pushed through a second phase of health reform, intended to constrain spending and expand the supply of primary-care doctors to take care of newly insured patients. Debate still swirls whether this second law, two months old, will help.
In the meantime, the emphasis here on insurance is producing results, imperfect as they are at times. Travis Lynn, who renewed his Commonwealth Care coverage through the help line, was dismayed last winter when the program dropped him because he briefly had a higher-paying job. It took him months to get his coverage back, even though he had quit that job because he was unable to walk for weeks after surgery he needed from stepping hard on a plastic champagne glass at a New Year's Eve celebration.
Jaclyn Michalos believes Commonwealth Care saved her life. A waitress and high school field hockey coach who will turn 29 next week, she had a teaching job right out of college that came with insurance. After she left teaching, she signed up for a policy on her own. It cost $500 a month, nearly one-third of her income. As soon as the first bill arrived, she wrote to the insurance carrier to cancel it.
So Michalos had been uninsured for two years when she noticed a lump in her left breast. "I saved up my money," she said, and went to a doctor, who told her not to worry about it. Still, the lump persisted, and a few months after Michalos joined Commonwealth Care, she went for a physical with a new doctor, who referred her for tests that diagnosed her breast cancer.
Commonwealth Care covered her double mastectomy and silicone implants. She did not pay a thing.