Click here to download this Open Letter as a Word file.

Dear Senator Kennedy:

We understand that you are working energetically on a comprehensive health care reform bill. We write as Massachusetts physicians and as your constituents who have experienced firsthand the consequences of our state’s health care reform. We seek to alert you to the defects in the Massachusetts approach and to advise that you push, instead, for a single-payer reform.

At certain junctures in history, the obstacles of the past melt in the heat of a rising popular demand for change. Now is such a time.

You once proudly described yourself as “an old single-payer advocate,” and you have previously introduced model single-payer health reform legislation. We urge you to return to that vision now when your tremendous influence could make this truly just and practical plan a reality.

Please consider the simplicity, cost effectiveness and humanity of a single-payer plan, which could be implemented comparatively easily like traditional Medicare. Any plan that retains private insurers will add layers of bureaucracy and fail to control costs, dooming the noble effort to assure good care for all.

The Massachusetts reform is illustrative of these problems. Costs have skyrocketed -rising far faster than anticipated. Yet hundreds of thousands remain uninsured and the number of patients requiring free care has fallen by only a third. Surveys show that one of every seven Massachusetts residents still can’t afford the care they need, and among patients directly affected by the new law, more say it has hurt than helped them. We fear that worse is just around the corner; money needed to fund the reform is being drained from safety-net providers who still carry a heavy burden of care for the uninsured and underinsured.

We ask that you introduce in the Senate legislation modeled on H.R. 676, which gained the support of 94 representatives in 110th Congress, and which has the backing of the U.S. Conference of Mayors, hundreds of unions, and thousands of physicians.

We urge you to be our Tommy Douglas - the founder of Canada’s national health program, who according to surveys remains the most beloved of all Canadians. Surely we deserve the health benefits that are guaranteed in every other developed nation - all medically necessary care, and freedom from the fear of economic ruin due to illness. Only a move to single payer can cut bureaucratic waste, allowing an affordable expansion of care.

We must not squander the opportunity of this momentous time. With your experience and stature you are uniquely able to ensure that generations to come will enjoy the legacy of health care as a human right.

• Leon Eisenberg, MD
  Professor of Social Medicine Emeritus, Harvard Medical School
• Susanne L. King, MD
  Child and Adolescent Psychiatrist, Lenox
• Rachel Nardin, MD
  Neurology, Beth Israel Deaconess Medical Center
• Michael Kaplan, MD
  Family Physician, Lee Family Practice
• Bernard Lown, MD
  Nobel Laureate
  Professor Emeritus, Harvard School of Public Health
• James Recht, MD
  Staff Psychiatrist, Cambridge Health Alliance
• Steffie Woolhandler, MD, MPH
  Associate Professor of Medicine, Harvard Medical School

Jill B. Schiff, MD
Brookline, MA

Ira Mintzer, MD
Newton Center, MA

David Bor, MD
Cambridge, MA

Barbara Ogur, MD
Cambridge, MA

Richard Pels, MD
Newton, MA

Alan Meyers, MD, MPH
Cambridge, MA

Mardge Cohen
Jamaica Plain, MA

Michael L. Glenn, MD
Medford, MA

Joseph McCabe
Cambridge, MA

Janet R. Magnani
Ashland, MA

Karen Victor, MD
Brookline, MA

Thomas F. Plaut, MSW
Amherst, MA

Martin I. Broder, MD
Springfield, MA

Mark P. Eisenberg, MD
Charlestown, MA

Barbara J Katz, MD
Jamaica Plain, MA

Roger Spingarn, MD
Newton Centre, MA

David M. Keller, MD
Webster, MA

John Jainchill, MD
Brookline, MA

Richard C. Evans, MD
Great Barrington, MA

Michael D’Alessandro, MD
South Hadley, MA

Naomi Barbara Dworkin
Belmont, MA

Seward B. Rutkove, MD
Boston, MA

Ashley Coopland
Longmeadow, MA

Ante Lundberg
Auburndale, MA

Henry W. Rosenberg, MD
Northampton, MA

Anthony Schlaff
Brookline, MA

Alan Drabkin
Boston, MA

Julie Silberman, MD
Cambridge, MA

Stephen A. Eipper, MD
Deerfield, MA

Martha A. Nathan, MD
Springfield, MA

Mary Aileen Dame, MD
Medford, MA

Thomas C. Sterne
Chelsea, MA

Bonnie Norton, MD
Jamaica Plain, MA

Joel Snider, MD
Cambridge, MA

David J. Geltman, MD
Jamaica Plain, MA

Ronald D. Schwartz
Fall River, MA

John V. Walsh
Cambridge, MA

Gerald Hass
Boston, MA

Peter V. Tishler, MD
Plymouth, MA

Jayne Doherty, MD
Lexington, MA

Russell Phillips
Newton, MA

Donna Ruth Cooper, MD
Provincetown, MA

Steven Atlas, MD
Cambridge, MA

George Ellsworth
Brookline, MA

Joel E. Rosen, MD
Northampton, MA

Charles Welch, MD
Cambridge, MA

Theodore M. Shoemaker, MD
Boylston, MA

Gordon Winchell, MD
Lincoln, MA

Priscilla P. Shaheen, RN
Methuen, MA

J Wesley Boyd, MD, PhD
Cambridge, MA

John F. Mueller
Rochester, MA

David Kraft, MD, MPH
Amherst, MA

Lindsey C. Kiser, MD
Needham Heights, MA

Robert McKersie, MD
Boxford, MA

Elizabeth Kissinger, MD
Cambridge, MA

Charles D. Howell
Westwood, MA

Patricia Downs, MD
Brookline, MA

Leslye Heilig, MD
Great Barrington, MA

Victor Gurewich, MD
Cambridge, MA

O’Malley Brian
Provincetown, MA

Max O’Donnell
Boston, MA

Eugene J. Fierman, MD
Brookline, MA

George Milowe, MD
Malden, MA

Jeremiah Schuur, MD
Cambridge, MA

Joellen W. Hawkins
Auburndale, MA

Lucy Candib, MD
Worcester, MA

Robert Jandl
North Adams, MA

Richard Balaban, MD
Brookline, MA

Walter Gamble, MD
Brookline, MA

Bruce Hurter, MD
Shrewbury, MA

Stanley Kilty, MD
Newburyport, MA

George Hardman, MD
Sherborn, MA

N. Thorne Griscom
Lexington, MA

Barry Poret
Turners Falls, MA

Shelly Berkowitz, MD
Northampton, MA

Richard Bail
Watertown, MA

Robert A. Petersen, MD
Boston, MA

Rachel Seidel
Cambridge, MA

Carol Langford, MD
Duxbury, MA

Ronald B. Durning
Adams, MA

Meredith Martin, MD
Framingham, MA

Robert D. Basow, MD
Hopkington, MA

Walter J. Alt
Amesbury, MA

Patricia Raney
Boston, MA

Donnah Nickerson-Reti, MD
Lexington, MA

David Kaufman, MD
Florence, MA

Richard Oliver Heck, MD
Great Barrington, MA

Hugh S. Fulmer
Northboro, MA

Alexandra K. Rolde
Weston, MA

Paul Vinger, MD
Concord, MA

Warnie L. Webster
Cambridge, MA

Bruce L. Bender
Boylston, MA

Anthony J. Costello
Jefferson, MA

Wayne A. Miller
West Barnstable, MA

Masha J. Etkin, MD
Brookline, MA

Sylvia A. Fine, MD
Somerville, MA

Roger R. Jean-Charles
Boston, MA

Cathy L. Vanden Heuvel
Brookline, MA

James R. Garb
Yarmouth Port, MA

Melvin Chalfen, MD
Lexington, MA

Thomas A. Johnson, MD
Worcester, MA

Daniel Kamin
Somerville, MA

Wayne Altman, MD
Woburn, MA

Richard A. Parker, MD
Newton Highlands, MA

Jeanette Callahan, MD
Roxbury, MA

Daniel W. Zinn, MD
Greenfield, MA

Robert Horowitz, MD
Amherst, MA

Edward Lowenstein, MD
Cambridge, MA

Douglas P. Kiel
Boston, MA

Bruce Weinraub
Northhampton, MA

John F. Crigler, Jr.
Wellesley, MA

Robert Sumner, MD
Marlborough, MA

Jessica R. Roth, MD
Cambridge, MA

Lenard Lesser, MD
Boston, MA

David Lotto, MD
Pittsfield, MA

Carolyn Laura Augart, MD
Lawrence, MA

Jennifer Brody, MD
Brighton, MA

Winfred del Mundo, MD
Milton, MA

Leo Parnes, MD
Newton, MA

Jocelyne Caplow, MD
Newton Centre, MA

Paul Allen, MD
Lexington, MA

Michael A. Lambert, MD
Brookline, MA

Judith Herman, MD
Cambridge, MA

Donald L. Slovin, MD
Sharon, MA

Renee McKinney, MD
Boston, MA

Roberta Berrien
Dennis, MA

Karen Lasser, MD
Cambridge, MA

Saverio Maviglia, MD
Medfield, MA

David Remis, MD
Springfield, MA

Jody Naimark, MD
Winchester, MA

Michael Hochman, MD
Boston, MA

Aubrey Milunsky
Boston, MA

Andreas Laddis, MD
Shrewsbury, MA

Timothy Davis
Medfield, MA

Jeffrey Geller, MD
Worcester, MA

Karen E. Lasser
Chestnut Hill, MA

Daniel P. Alford, MD
Needham, MA

Carl A. Soderland
Ipswich, MA

Leslie Dubinsky
Palmer, MA

Rona Klein, MD
Boston, MA

Milton Hirshberg, MD
South Harwich, MA

Suzanne Stoterau
Lincoln, MA

Christina Wai, MD
Boston, MA

James Kolb, MD
Belmont, MA

Maureen McDonald
Marshfield, MA

Ron Distajo, MD
Cambridge, MA

David S. Lee, MD
Mansfield, MA

Giulia Scarantino
Methuen, MA

Wilsa J. Ryder, MD
Provincetown, MA

Naomi Rappaport
New Bedford, MA

Andrew Linsenmeyer
Boston, MA

Michael J. Abele, MD
Lowell, MA

David W. Bates, MD
Watertown, MA

Richard McGinn, MD
Greenfield, MA

Brenda L. Johnson, MD, MA
Winchester, MA

Donald Green, MD
Reading, MA

Padma Balasubramanian, MD
Newton, MA

Leonard W. Kaplan, MD
Brookline, MA

Andrew Perry
Newton, MA

Harold W. Forbes
Arlington, MA

Candace Foster, MD
Lincoln, MA

An Sokolovksa
Cambridge, MA

Kate Koplan, MD
Brookline, MA

William V Dewhirst, MD
Pittsfield, MA

Cheryl Hamlin, MD
Arlington, MA

Gordon Fellman
Cambridge, MA

William Schmitt, MD
Cambridge, MA

Rosemary Kofler, RN
Amherst, MA

Wallace & Clare Ritchie
Salem, MA

Michael D’Intinosanto, RN
Winchendon, MA

Michelle Hauser, MD
Boston, MA

Vaughn Harding
Hyannis, MA

Victoria Merson Pickwick, RN
Siasconset, MA

Timothy Macchio
Boston, MA

Gale Maynard
Melrose, MA

Mary Ellen Daly O’Brien, RN
Haverhill, MA

Carol MacDougall, RN
Wilmington, MA

Adam Field
Boston, MA

Richard Kofler
Amherst, MA

Michelle Kofler
South Deerfield, MA

Edythe Cox
Hingham, MA

Leena Gandhi, MD, PhD
Boston, MA

Jay Caplan
Whatley, MA

Kelsey L. Dicker
Quincy, MA

Ann Roy
Southampton, MA

Stephen Hoy
Beverly, MA

Donald Slovin, MD
Sharon, MA

Stanley Shapshay, MD
Richmond, MA

Marcia Angell
Cambridge, MA

Leonardo Velazquez
N. Dartmouth, MA

Leonardo J. Velazquez
N. Dartmouth, MA

Geraldine Zagarella, MD
Jamaica Plain, MA

Robert Berger
Brookline, MA

Neil Kudler
Springfield, MA

Judith Goldberg, MD
Wayland, MA

Elise Foster, MD
Beverly, MA

Malachy Shaw-Jones
Arlington, MA

Sally Weylman
Cambridge, MA

Laurel Davis-Delano
Northampton, MA

Paul Dixon
Orleans, MA

Lisa Dobberteen, MD
Cambridge, MA

Jean Grossholtz
South Hadley, MA

Kathryn Hunt
Newton, MA

Jeffrey Rivard
Natick, MA

Anne Warren
Boston, MA

Betty Munson
Cambridge, MA

Paul McBratney-Owen
Cambridge, MA

Kimberly Sue, MD, PhD
Cambridge, MA

David Larrabee, MD
Charlton, MA

Richard Wein, MD
Boston, MA

Rebecca Rogers, MS
Brookline, MA

Tom Hagamen
Deerfield, MA

Gertrude Bull
East Falmouth, MA

Jeffrey Gill
Shirley, MA

Lisa Carlson, MD
Melrose, MA

Wendell D. Wyatt, MD
Greenfield, MA

Richard Corkey, MD
Boston, MA

Ramon Greenberg, MD
Jamaica Plain, MA

Larissa Lucas, MD
Salem, MA

Phil Wilson
Northampton, MA

Jay M. Pomerantz, MD
Longmeadow, MA

Jerry Durbin
Needham, MA

Jan Schwaner, MD
Wellesley Hills, MA

Sally Thompson, MD
Acton, MA

Lauri Robertson, MD
Nantucket, MA

Sarah Minden
Boston, MA

Kirsten Austad
Boston, MA

Nancy Rappaport
Cambridge, MA

Elinor Kelliher, MD
West Springfield, MA

Michael Garrity, MD
Charlestown, MA

Kimberly Sue, MD, PhD
Cambridge, MA

Sandeep Kumar, MD
Newton, MA

Michael Alexander
Boston, MA

Rachel Broudy
Cambridge, MA

Brian Green
Somerville, MA

Monica Demasi, MD
Somerville, MA

Ruth Barron
Cambridge, MA

Gerard Coste
Lexington, MA

Bari Brodsky
Cambridge, MA

David Baron, MD
Lexington, MA

Kirsten Meisinger, MD
Somerville, MA

Megan Callahan
Cambridge, MA

Martha Sweezy
Cambridge, MA

Jane Fogg, MD
Needham, MA

Donna Mathias, MD
Brookline, MA

Karina Lund, MD
Quincy, MA

Mary McCormick, MD
North Andover, MA

Melissa Bartick
Cambridge, MA

Shahram Khoshbin, MD
Boston, MA

Barbara Dworetzky
West Roxbury, MA

Christopher Shanahan
West Roxbury, MA

William Taylor, MD
Newton, MA

Alexandra Golby, MD
Boston, MA

Greg Lipshutz, MD
Newton, MA

Gregory Hagan, MD
Somerville, MA

Maurice Martin, MD
Somerville, MA

Pieter Cohen
Brookline, MA

Theodore Murray, MD
Somerville, MA

Karen Wood, MD
Chestnut Hill, MA

William Kinsey, MD
Cambridge, MA

J. Elliott Taylor, MD
Falmouth, MA

James Peterson
Adams, MA

Barry Saver
Worcester, MA

Charles Taylor, MD
Cambridge, MA

Susan Racine, MD
West Roxbury, MA

Robert P. Marlin, MD
Arlington, MA

Karin Hemmingsen, MD
Attleboro, MA

Richard Balaban, MD
Somervilled, MA

Julia Ragland
Needham, MA

Allen Ross, MD
Montague, MA

Erik Deede, MD
Sudbury, MA

John Jewett
Jamaica Plain, MA

Milena Pavlova
Boston, MA

Edward Bromfield, MD
Newton, MA

Robert Shmerling
Boston, MA

Diane London, MD
Dover, MA

Elizabeth Kass, MD
Brookline, MA

Howard Wolpert
Brookline, MA

Reisa Sperling, MD
Boston, MA

Kelly Ford, MD
Boston, MA

Saurabh Saluja, MD
Boston, MA

John Stoeckle, MD
Winchester, MA

Christopher Nauman, MD
Brockton, MA

Matthew Ehrlich, MD
Cambridge, MA

Lee Cranberg, MD
Chestnut Hill, MA

Michael Barza, MD
Chestnut Hill, MA

Corey Fehnel, MD
Boston, MA

Louis Caplan, MD
Chestnut hill, MA

Lynne Brodsky, MD
Winchester, MA

Peter Cohen
Newton, MA

Robert Reece, MD
North Falmouth, MA

Rajani LaRocca, MD
Charlestown, MA

Barry Mills
Brighton, MA

Michael Rich, MD
Boston, MA

Saverio Maviglia, MD
Medfield, MA

Elizabeth Ross, MD
Boston, MA

John Jewett
Jamaica Plain, MA

Jan Foose
Gt. Barrington, MA

Robert Lange
Wayland, MA

Richard Sens, MD
Cambridge, MA

Nance Goldstein, PhD
Cambridge, MA

Eve Spangler
Newton, MA

Sarah Weaver
North Reading, MA

Seth Gale, MD
Cambridge, MA

Melissa Greenspan, MD
Florence, MA

Jacquelyn Wolf, PhD
Amherst, MA

Barry Levy, PhD
Amherst, MA

William Cutler, MD
Leeds, MA

Catherine Horwitz, MD
Boston, MA

Joel Alpert, MD
Boston, MA

Ellen Z. Kaufman
Northampton, MA

John Hanson
Chicago, IL

Deborah Wolozin, PhD
Sudbury, MA

Sarah Goff, MD
Springfield, MA

Rosemary Duda, MD
Boston, MA

Alonzo Shirin, MD, MPH
Brookline, MA

Hanni Stoklosa, MS
Arlington, MA

Brian Block, MS
Brookline, MA

Mike Matergia, MS
Boston, MA

George Corey, MD
West Hatfield, MA

Anne Weaver, MD
Montague, MA

Alan Berkenwald, MD
Florence, MA

Tereza Jaquez
Stoneham, MA

Shonali Saha
Somerville, MA

Mirna Mejia
SOMERVILLE, MA

Nicholas Carson, MD
Somerville, MA

Catianne Dias
Somerville, MA

Charlotte Golden
West Roxbury, MA

Richard Pels, MD
Newton, MA

Huiyuan Lightner
Northborough, MA

Miriam Goldfarb, MD
Cambridge, MA

Stephen Pinals, MD
Framingham, MA

Michael Williams
Cambridge, MA

Heidi Ashih, MD, PhD
Cambridge, MA

Rachel Wheeler
Concord, MA

David Himmelstein
Cambridge, MA

Thomas Myers
Somerville, MA

Cheryl Sneed
Malden, MA

Emily Straus
Somerville, MA

Melanie Brunt, MD, MPH
Chestnut Hill, MA

Susan Grosdov
Saugus, MA

Nancy Vargas
Peabody, MA

Sarah Rosenberg-Scott, MD, MPH
Boston, MA

Sara Karp, MD
Malden, MA

Somava Stout, MD
Lexington, MA

Laura Obbard, MD
Cambridge, MA

Elissa Kleinman, MD
Brookline, MA

Maren Batalden
Roslindale, MA

Page Carter
Somerville, MA

Paul Geltman, MD
Waban, MA

Sarah Crane, MD
Cambridge, MA

Zarpash Babar, MD
Cambridge, MA

Goldie Eder
Cambridge, MA

Ruth Gerson, MD
Cambridge, MA

Andrea Gordon, MD
Melrose, MA

Pedro M. Barbosa
Arlington, MA

Albert H Fine, MD
Revere, MA

Evan Waldheter
Cambridge, MA

Catherine Pemberton
Cambridge, MA

Timothy Stephens, MD
Cambridge, MA

Suen Winnie
Cambridge, MA

Margaret Lanca
Lexington, MA

Francisco Bonilla
Canton, MA

Hilary Worthen, MD
Newton, MA

Jill Forney
Cambridge, MA

Monty Monroe
Melrose, MA

Gail Shulman, MD
Cambridge, MA

Lynne Seeley, RN
North Reading, MA

Sarah Muzzy
Somerville, MA

Elisabeth Traumann
Somerville, MA

Pattie Heyman
Cambridge, MA

Jacqueline Bisbee
Charlestown, MA

David Fish, MD
Boston, MA

Judith Casarella
Lincoln, MA

Josephine Brown
Cambridge, MA

Paula Cushner, RN
Weymouth, MA

Xenia Johnson, MD
Cambridge, MA

Marshall Forstein, MD
Jamaica Plain, MA

Paige Katzenstein
Beverly, MA

Margaret Buckley, RN
Arlington, MA

Louise Perrault
Wakefield, MA

David Smith
Somerville, MA

Arthur Spector, MD
Cambridge, MA

Ellen Lapowsky
Jamaica Plain, MA

Victor Saldanha, MD
Everett, MA

Judith Hunt
Cambridge, MA

Lori Tishler, MD
Boston, MA

Ravi Gatha
Needham, MA

Barry Mills, MD
Brighton, MA

Marci Yoss, MD
Florence, MA

Norine Philipp
Jamaica Plain, MA

Matthew Ruble
Cambridge, MA

Gail Levine, MD
Jamaica Plain, MA

James LaFortune
Somerville, MA

Jonathan Strongin, MD
Brookline, MA

Blake Cady, MD
Brookline, MA

Anne Fabiny, MD
Brookline, MA

Katherine Miller, MD
Somerville, MA

Abigail Judge
Cambridge, MA

Laura Pabo
Watertown, MA

Margaret Fox
Somerville, MA

Sabina Hak
Medford, MA

Dominika Seidman
Boston, MA

David Gunther, MD
Boston, MA

David Osler
Cambridge, MA

Betty Lee
Cambride, MA

Marianna Kong
Boston, MA

Marie Hobart, MD
Shrewsbury, MA

Simeon Kimmel, MS
Jamaica Plain, MA

Sally Thompson
Somerville, MA

Penny Adams
Cambridge, MA

Brian Walsh, RN
Reading, MA

Amanda Zurick
Cambridge, MA

Patricia Mansfield
Peabody, MA

Leslie Bodvar
Revere, MA

Cynthia MacDougall
Cambridge, MA

Whitney Rohrer
Cambridge, MA

Melissa Coco
Belmont, MA

Andrew Jorgensen, MD
Dedham, MA

Robert Nace
Somerville, MA

Donna Ferri
Malden, MA

George Dominiak, MD
Belmont, MA

Alexander Morgan
Newton, MA

Amy Itzkovitz
Concord, MA

Paul Thaler
Florence, MA

Bill Bicknell, MD, MPH
Marshfield, MA

Miriam Tepper, MD
Somerville, MA

Sheila Cleary, MD
Lexington, MA

Erin Boggs
Cambridge, MA

Amber Lerma, MD
Somerville, MA

Randalal Paulsen, MD
Chestnut Hill, MA

Jayme Shorin
Cambrdige, MA

Joan Rabin
Amherst, MA

Edos Igbinosa, RN
North Andover, MA

Pano Yeracaris, MD, MPH
Chestnut Hill, MA

Valerie Ososky
Roslindale, MA

Peggy Brown
Cambridge, MA

Kathleen Lentz, MD
Westford, MA

Katherine Wenger
Wayland, MA

Hugh Roberts, MD
Leverett, MA

William Copeland
Northfield, MA

Linda Klaiman
Marblehead, MA

Nancy Crouse
Quincy, MA

Audrey Gautreau
Malden, MA

Bert Fernandez, MD
Shutesbury, MA

William Zinn, MD
Belmont, MA

Judy Seifert
Medford, MA

Margaret A Lynch
Cambridge, MA

Jennifer Potter, MD
Brookline, MA

David Slack, MD
Florence, MA

Stanley Sagov, MD
Chestnut Hill, MA

Elizabeth Parsons
Watertown, MA

Sharleen Johnston, RN
Attleboro, MA

Nina Marlowe, MD
Somerville, MA

Erik Fung
Brighton, MA

Muzzamal Habib, MD
Brighton, MA

Leora Fishman, MD
Somerville, MA

Emily Gregory, MD
Cambridge, MA

Melanie Adem
Somerville, MA

Arthur Safran, MD
Newton, MA

Jill Schiff
Brookline, MA

Francis Coughlin
Boston, MA

Richard Evans, MD
Great Barrington, MA

Wendy Gray, MD
Cambridge, MA

Cassie Frank, MD
Cambridge, MA

Julie Meyers, MS
Pawtucket, RI

Wayne Altman
Woburn, MA

Blake Cady
Brookline, MA

Jessica Stewart
Brookline, MA

Clea Lopez
Cambridge, MA

Donald Chauls
Sudbury, MA

Martha Sweezy, PhD
Cambridge, MA

Don Steele, PhD
Mansfield, MA

Albert H Fine, MD
Revere, MA

Christopher Grieves, MD
Cambridge, MA

Pieter Cohen, MD
Brookline, MA

Jeremy Keller, MD
Cambridge, MA

Hannah Olivet, MD
Cambridge, MA

Elizabeth Parlee, MD
Somerville, MA

Cynthia Telingator, MD
Cambridge, MA

Daniel Tarsy, MD
Boston, MA

Soma Sengupta
Brookline, MA

Yamini Saravanan, MD
Brighton, MA

Amy Colson
Newton, MA

David K. Simon, MD
Brookline, MA

Laura Sullivan, MD
Jamaica Plain, MA

Anne Fabiny, MD
Cambridge, MA

Jean Matheson, MD
Chestnut Hill, MA

Kristen Goodell
Winchester, MA

Andrea Gordon, MD
Melrose, MA

Lior Givon, MD, PhD
Cambridge, MA

Thomas Goldberger, MD
Newton, MA

Katharine Kosinski, MD
Cambridge, MA

William Horgan, MD
Everett, MA

Gerard Coste, MD
Lexington, MA

Claudia Epelbaum, MD
Cambridge, MA

Lisa Dobberteen, MD
Cambridge, MA

Luis Lobon, MD
Chestnut Hill, MA

Kevin Dennehy
Swampscott, MA

Geoffrey Pechinsky, MD
Lexington, MA

Robert Dickman, MD
Newton, MA

Paul Allen
Lexington, MA

Pushpa Narayanaswami, MD
Chestnut Hill, MA

Amanda Klein, MD
Dedham, MA

Jennifer Retsinas, MD
Cambridge, MA

Pano Yeracaris
Chestnut Hill, MA

Rose Goldman, MD
Jamaica Plain, MA

Amy Bauer
Cambridge, MA

Traci Brooks, MD
Jamaica Plain, MA

Judith Herman, MD
Cambridge, MA

Miriam Goldfarb, MD
Cambridge, MA

Madeline Barott, MD
Cambridge, MA

Melissa Bartick, MD
Cambridge, MA

Ramona Dvorak, MD
Cambrdige, MA

Download this Open Letter as a PDF file.

Download this Open Letter as a Word file.

MASSACHUSETTS LABOR FOR HEALTH CARE

c/o Jobs with Justice, 3353 Washington Street, Boston, MA 02130

Phone: (617) 524-8778, Fax: (617) 524-8996, Email: jwj@massjwj.net

February 18, 2009

Honorable Barack Obama, President

The White House

1600 Pennsylvania Ave NW

Washington, DC 20500

Dear President Obama,

We applaud your commitment to enact legislation that will improve health care in the United States.  Health care continues to be a critical issue for workers at the bargaining table and — as the crisis in the auto industry shows — without a real solution responsible employers lose their competitive edge while employees suffer.

The undersigned labor leaders from Massachusetts, ask that you pursue a strong agenda for national, universal, publicly-funded health care as the best solution to address out-of-control health care costs and unacceptable levels of health care disparities.

The best way to achieve your goals of universality, quality, and cost effectiveness is a national program based on improving and expanding Medicare to cover everyone.  This would be accomplished by passing HR 676, the “Medicare for all” legislation.

Although much-touted by some policy makers in Washington, the Massachusetts Plan has failed to address our concerns about costs and disparities and in some cases, has even made them worse.

The chief problem with the Massachusetts plan is that it leaves private insurance companies at the center of the system through an individual mandate and expensive public subsidies supported by taxes for plans that still don’t provide enough coverage.

The law is too expensive for many individuals forced to buy health insurance.  It has failed to control costs and it has cost the state far more than initially projected.  As a result, many critical health care facilities that serve low-income communities are facing huge cuts, while health care premiums continue to rise by double digits year after year.  The Massachusetts Plan is widely recognized as unsustainable and now that we are facing an economic crisis, it is even more problematic.

As John Sweeney, President of the AFL-CIO has said, “Who would have thought that Massachusetts …would take a page out of the Newt Gingrich playbook for health care reform?  Forcing uninsured workers to purchase health care coverage or face higher taxes and fines is the cornerstone of Mr. Gingrich’s health care reform proposals.  And it is unconscionable that Massachusetts has adopted this misguided individual mandate.”

We are part of a growing number of labor leaders in the labor movement who support HR 676, the “Medicare for All” bill, that is very similar to previous efforts sponsored by our own Senator Edward Kennedy.  We believe that, given the lessons of Massachusetts, this approach is the most fiscally prudent and morally imperative direction for successful health care reform.

We thank you in advance for your commitment to health care reform and look forward to working with you to make it a reality.

Sincerely,

Pauline Arguin, President, UE Local 204, Esterline Ind., Haskon Div., Taunton, MA

Cliff Alzes, President, IAMAW Local 2654, Gloucester, MA

Barbara Beckwith and Charles Coe, Co-chairs, National Writers Union / UAW, Boston Chapter

Alex Brown, Vice President, IUE-CWA Local 201, Lynn, MA

Myles Calvey, Business Manager, IBEW Local 2222, Dorchester, MA

Jeff Crosby, President, North Shore Labor Council, AFL-CIO, Lynn, MA

Russ Davis, Director, Massachusetts Jobs with Justice, Boston, MA

Wilfred “Willie” Desnoyers, President, UAW MA State CAP Council

Sandy Eaton, Chair, Mass Nurses Association Region 5, Canton, MA

James Foley, Business Rep., IAMAW District 15, Boston, MA

Christine Folsom, Chair, Mass Nurses Association Region 1, Northampton, MA

Paul Georges, President, Merrimack Valley Central Labor Council, AFL-CIO, Lowell, MA

Mark Govoni, V.P. & Political Director, UFCW Local 1445, Dedham, MA

Fiore Grassetti, President Hampshire Franklin Labor Council, AFL-CIO, Northampton, MA

Donna Johnson, President, University Staff Association/MTA, UMass Amherst, MA

Donald Keith, President, UE Local 269, Erving Paper Co., Erving MA

John Kelly, President, IBEW Local 2321, North Andover, MA

Peter Knowlton, District President, UE Northeast Region, Taunton, MA

Stephen Lewis, Treasurer, SEIU Local 509, Watertown, MA

Bill Lynch, President, UE Local 262, Boston, MA

Kathy Melish, President, UAW Local 1596, Canton, MA

Dick Monks, Vice-President, IUOE Local 877, Norwood, MA

Joseph Montagna, Business Agent, AEEF-CWA Local 1300, WGBH, Somerville, MA

Carl Olsen, Pres., UE Local 248, Mattapoisett, MA

Ron Patenaude, President of UAW Local 2322, Holyoke, MA

Randall Phillis, President, Massachusetts Society of Professor/MTA, Amherst, MA

Beth Piknick, President, Mass Nurses Association, Canton, MA

James Pimental, Reg. VP, Southeastern Mass. CLC and Secr-Treas, Southeastern Mass. Building Trades Council

Julie Pinkham, Exec. Dir., Mass Nurses Association, Canton, MA

Frank Rigiero, National Business Agent, American Postal Workers Union, AFL-CIO, Worcester, MA

Cynthia Rodrigues, President Greater Southeastern Massachusetts Labor Council, AFL-CIO, New Bedford, MA

Lynne Starbard, Chair, Mass Nurses Association Region 2, Worcester, MA

Ed Starr, Business Mgr., IBEW Local 2321, North Andover, MA

Stephanie Stevens, Chair, Mass Nurses Association Region 3, Sandwich, MA

Richard Stutman, President, Boston Teachers Union, AFT, Boston, MA

Paul Toner, Vice President, Mass Teachers Association, Boston, MA

Daniel B. Totten, President, Boston Newspaper Guild, TNG-CWA Local 31245

Don Trementozzi, President, CWA Local 1400, Boston, MA

Gael Wakefield, President, UE Local 274: Franklin County, Greenfield, MA

Anne Wass, President, Mass Teachers Association, Boston, MA

Jon Weissman, Secr-Treas, Pioneer Valley Labor Council, AFL-CIO, Springfield, MA

Brian Zahn, Chair, Mass Nurses Assoc. Region 4, Peabody, MA

* Affiliations are listed for identification purposes only.

cc: Senator Edward Kennedy

Senator John Kerry

Massachusetts Congressional delegation

Click here to download the full text of An Act to Establish The Massachusetts Health Care Trust (HB 2127) as a Word file.

The full text of the bill is as follows:

AN ACT TO ESTABLISH THE MASSACHUSETTS HEALTH CARE TRUST (HB 2127).

Be it enacted by the Senate and House of Representatives in General Court assembled, and by the authority of the same, as follows:

The Massachusetts General Laws are hereby amended by adding the following new chapter:-

CHAPTER ___

MASSACHUSETTS HEALTH CARE TRUST

Table of Contents

• Section 1: Preamble
• Section 2: Definitions
• Section 3: Establishment of the Massachusetts Health Care Trust
• Section 4: Powers of the Trust
• Section 5: Purposes of the Trust
• Section 6: Board of Trustees; Composition; Powers and Duties
• Section 7: Executive Director; Purpose and Duties
• Section 8: Regional Division; Director, Offices, Purposes and Duties
• Section 9: Administrative Division; Director; Purpose and Duties
• Section 10: Planning Division; Director; Purpose and Duties
• Section 11: Information Technology Division; Purpose & Duties
• Section 12: Quality Assurance Division; Director; Purpose and Duties
• Section 13: Eligible Participants
• Section 14: Eligible Health Care Providers and Facilities
• Section 15: Budgeting and Payments to Eligible Health Care Providers and Facilities
• Section 16: Covered Benefits
• Section 17: Wraparound Coverage for Federal Health Programs
• Section 18: Establishment of the Health Care Trust Fund
• Section 19: Purpose of the Trust Fund
• Section 20: Funding Sources
  • 20.A: Overview
  • 20.B: Health Care Funding
  • 20.C: Consolidating Public Health Care Spending and Collateral Sources of Revenue
    • 20.C.1: Consolidation of State and Municipal Health Care Spending
    • 20.C.2: Federal Sources of Revenue
    • 20.C.3: Collection of Collateral Sources of Revenue
    • 20.C.4: Retention of Funds
  • 20.D: Transitional Provisions
• Section 21: Insurance Reforms
• Section 22: Health Trust Regulatory Authority
• Section 23: Implementation of the Health Care Trust

Section 1: Preamble.

The foundation for a productive and healthy Massachusetts is a health care system that provides equal access to quality health care for all its residents. Massachusetts spends more on health care per capita than any other state or country in the world, causing undue hardship for the state, municipalities, businesses, and residents, but without achieving universal access to quality health care. The Health Care Trust will allow us to achieve and sustain the three main pillars of a just, efficient health care system: cost control and affordability, universal access, and high quality medical care.

(a) COST CONTROL AND AFFORDABILITY

Controlling costs is the most important component of establishing a sustainable health care system for the Commonwealth.  The Health Care Trust will control costs by establishing a global budget, by achieving significant savings on administrative overhead through consolidating the financing of our health care system, by bulk purchasing of pharmaceuticals and medical supplies, and by more efficient use of our health care facilities.  The present fragment health care system also leads to a lack of prevention. By integrating services and removing barriers to access, the Health Care Trust will lead to early detection and intervention, often avoiding more serious illnesses and more costly treatment.

(b) UNIVERSAL EQUITABLE ACCESS

Hundreds of thousands of Massachusetts residents still lack health insurance coverage of any sort.  Even more residents are covered by plans requiring high deductibles and co-payments that make medical care unaffordable even for the insured.  The Health Care Trust will provide health care access to all residents without regard to financial status, ethnicity, gender, previous health problems, or geographic location.  Coverage will be continuous and affordable for individuals and families, since there will be no financial barriers to access such as co-pays or deductibles.

(c) QUALITY OF CARE

The World Health Organization rates health outcomes in the United States health care system lower than those of almost all other industrialized countries, and a number of developing countries as well. Poor health outcomes result from the lack of universal access, the lack of oversight on quality due to the fragmentation and complexity of our health care system, and the frequent lack of preventive and comprehensive care benefits offered under commercial health plans.  The Trust will reduce errors through information technology, improve medical care by eliminating much of the present administrative complexity, and emphasize culturally competent outreach and care. It will provide for input from patients on the functioning of the health delivery system.

Section 2: Definitions.

The following words and phrases shall have the following meanings, except where the context clearly requires otherwise:-

“Board” means the board of trustees of the Massachusetts Health Care Trust.

“Employer” means every person, partnership, association, corporation, trustee, receiver, the legal representatives of a deceased employer and every other person, including any person or corporation operating a railroad and any public service corporation, the state, county, municipal corporation, township, school or road, school board, board of education, curators, managers or control commission, board or any other political subdivision, corporation, or quasi-corporation, or city or town under special charter, or under the commission for of government, using the service of another for pay in the commonwealth.

“Executive Director” means the executive director of the Massachusetts Health Care Trust.

“Health care” means care provided to a specific individual by a licensed health care professional to promote physical and mental health, to treat illness and injury and to prevent illness and injury.

“Health care facility” means any facility or institution, whether public or private, proprietary or nonprofit, that is organized, maintained, and operated for health maintenance or for the prevention, diagnosis, care and treatment of human illness, physical or mental, for one or more persons.

“Health care provider” means any professional person, medical group, independent practice association, organization, health care facility, or other person or institution licensed or authorized by law to provide professional health care services to an individual in the commonwealth.

“Health maintenance organization” means a provider organization that meets the following criteria:

(1) Is fully integrated operationally and clinically to provide a broad range of health care services;

(2) Is compensated using capitation or overall operating budget; and

(3) Provides health care services primarily through direct care providers who are either employees or partners of the organization, or through arrangements with direct care providers or one or more groups of physicians, organized on a group practice or individual practice basis.

“Professional advisory committee” means a committee of advisors appointed by the director of the Administrative, Planning, Information, Technology, or any Regional division of the Massachusetts Health Care Trust.

“Resident” means a person who lives in Massachusetts as evidenced by an intent to continue to live in Massachusetts and to return to Massachusetts if temporarily absent, coupled with an act or acts consistent with that intent. The Trust shall adopt standards and procedures for determining whether a person is a resident. Such rules shall include:

(1) a provision requiring that the person seeking resident status has the burden of proof in such determination;

(2) a provision requiring reasonable durational domicile requirements not to exceed 2 years for long term care and 90 days for all other covered services;

(3) a provision that a residence established for the purpose of seeking health care shall not by itself establish that a person is a resident of the commonwealth; and

(4) a provision that, for the purposes of this chapter, the terms “domicile” and “dwelling place” are not limited to any particular structure or interest in real property and specifically includes homeless individuals with the intent to live and return to Massachusetts if temporarily absent coupled with an act or acts consistent with that intent.

“Secretary” means the secretary of the executive office of health and human services.

“Trust” means the Massachusetts Health Care Trust established in section five of this chapter.

“Trust Fund” means the Massachusetts Health Care Trust Fund established in section nineteen of this chapter.

Section 3. Establishment of the Massachusetts Health Care Trust.

There is hereby created an independent body, politic and corporate, to be known as the Massachusetts Health Care Trust, hereinafter referred to as the Trust, to function as the single public agency, or “single payer”, responsible for the collection and disbursement of funds required to provide health care services for every resident of the Commonwealth. The Trust is hereby constituted a public instrumentality of the commonwealth and the exercise by the Trust of the powers conferred by this chapter shall be deemed and held the performance of an essential governmental function. The Trust is hereby placed in the executive office of the health and human services but shall not be subject to the supervision or control of said office or of any board, bureau, department or other agency of the commonwealth except as specifically provided by this chapter.

The provisions of chapter two hundred sixty-eight A shall apply to all trustees, officers and employees of the Trust, except that the Trust may purchase from, contract with or otherwise deal with any organization in which any trustee is interested or involved: provided, however, that such interest or involvement is disclosed in advance to the trustees and recorded in the minutes of the proceedings of the Trust: and provided, further, that a trustee having such interest or involvement may not participate in any decision relating to such organization.

Neither the Trust nor any of its officers, trustees, employees, consultants or advisors shall be subject to the provisions of section three B of chapter seven, sections nine A, forty-five, forty-six and fifty-two of chapter thirty, chapter thirty B or chapter thirty-one: provided, however, that in purchasing goods and services, the corporation shall at all times follow generally accepted good business practices.

All officers and employees of the Trust having access to its cash or negotiable securities shall give bond to the Trust at its expense, in such amount and with such surety as the board of trustees shall prescribe. The persons required to give bond may be included in one or more blanket or scheduled bonds.

Trustees, officers and advisors who are not regular, compensated employees of the Trust shall not be liable to the commonwealth, to the Trust or to any other person as a result of their activities, whether ministerial or discretionary, as such trustees, officers or advisors except for willful dishonesty or intentional violations of law. The board of the Trust may purchase liability insurance for trustees, officers, advisors and employees and may indemnify said persons against the claims of others.

Section 4: Powers of the Trust.

The Trust shall have the following powers:

(1) to make, amend and repeal by-laws, rules and regulations for the management of its affairs;

(2) to adopt an official seal;

(3) to sue and be sued in its own name;

(4) to make contracts and execute all instruments necessary or convenient for the carrying on of the purposes of this chapter;

(5) to acquire, own, hold, dispose of and encumber personal, real or intellectual property of any nature or any interest therein;

(6) to enter into agreements or transactions with any federal, state or municipal agency or other public institution or with any private individual, partnership, firm, corporation, association or other entity;

(7) to appear on its own behalf before boards, commissions, departments or other agencies of federal, state or municipal government;

(8) to appoint officers and to engage and employ employees, including legal counsel, consultants, agents and advisors and prescribe their duties and fix their compensations;

(9) to establish advisory boards;

(10) to procure insurance against any losses in connection with its property in such amounts, and from such insurers, as may be necessary or desirable;

(11) to invest any funds held in reserves or sinking funds, or any funds not required for immediate disbursement, in such investments as may be lawful for fiduciaries in the commonwealth pursuant to sections thirty-eight and thirty-eight A of chapter twenty nine

(12) to accept, hold, use, apply, and dispose of any and all donations, grants, bequests and devises, conditional or otherwise, of money, property, services or other things of value which may be received from the United States or any agency thereof, any governmental agency, any institution, person, firm or corporation, public or private, such donations, grants, bequests and devises to be held, used, applied or disposed for any or all of the purposes specified in this chapter and in accordance with the terms and conditions of any such grant. Â Receipt of each such donation or grant shall be detailed in the annual report of the Trust; such annual report shall include the identity of the donor, lender, the nature of the transaction and any condition attaching thereto;

(13) to do any and all other things necessary and convenient to carry out the purposes of this chapters.

Section 5: Purposes of the Trust.

The purposes of the Massachusetts Health Care Trust shall include the following:

(1) To guarantee every Massachusetts resident access to high quality health care by:

(a) providing reimbursement for all medically appropriate health care services offered by the eligible provider or facility of each resident’s choice;

(b) funding capital investments for adequate health care facilities and resources statewide

(2) To save money by replacing the current mixture of public and private health care plans with a uniform and comprehensive health care plan available to every Massachusetts resident;

(3) To replace the redundant private and public bureaucracies required to support the current system with a single administrative and payment mechanism for covered health care services;

(4) To use administrative and other savings to:

(a) expand covered health care services;

(b) contain health care cost increases; and

(c) create provider incentives to innovate and compete by improving health care service quality and delivery to patients;

(5) To fund, approve and coordinate capital improvements in excess of a threshold to be determined annually by the executive director to qualified health care facilities to:

(a) avoid unnecessary duplication of health care facilities and resources; and

(b) encourage expansion or location of health care providers and health care facilities in underserved communities;

(6) To assure the continued excellence of professional training and research at Massachusetts health care facilities;

(7) To achieve measurable improvement in health care outcomes;

(8) To prevent disease and disability and maintain or improve health and functionality;

(9) To ensure that all Massachusetts residents receive care appropriate to their special needs as well as care that is culturally and linguistically competent;

(10) To increase satisfaction with the health care system among health care providers, consumers, and the employers and employees of the commonwealth;

(11) To implement policies which strengthen and improve culturally and linguistically sensitive care;

(12) To develop an integrated population-based health care database to support health care planning; and

(13) To fund training and re-training programs for professional and non-professional workers in the health care sector displaced as a direct result of implementation of this chapter.

Section 6: Board of Trustees; Composition; Powers and Duties.

The Trust shall be governed by a board of trustees with twenty-three members. The board shall include the secretary of health and human services, the secretary of administration and finance, and the commissioner of public health.

The Governor shall appoint: three trustees nominated by organizations of health care professionals who deliver direct patient care; one nominated by a statewide organization of health care facilities; one nominated by an organization representing non-health care employers; and a health care economist.

The Attorney General shall appoint: one trustee nominated by a statewide labor organization; two trustees nominated by statewide organizations who have a record of advocating for universal single payer health care in Massachusetts; one nominated by an organization representing Massachusetts senior citizens; one nominated by a statewide organization defending the rights of children; and one nominated by an organization providing legal services to low-income clients.

In addition, eight trustees, who are eligible to receive the benefits of the Massachusetts Health Care Trust but who do not fall into any of the aforementioned categories, shall be elected by the citizens of the Commonwealth, one from each of the Governor’s Council districts. Candidates shall run in accordance with Fair Campaign Financing Rules. In order to provide for staggered terms, from the first eight to be elected, two shall be elected for two years, three for three years, and three for four years. Afterwards, all elected trustees shall be elected for four-year terms. All elected trustees shall be eligible for reelection, which would enable them to serve a maximum of eight consecutive years.

Each appointed trustee shall serve a term of five years: provided, however, that initially four appointed trustees shall serve three year terms, four appointed trustees shall serve four year terms, and four appointed trustees shall serve five year terms. The initial appointed trustees shall be assigned to a three, four, or five year term by lot. Any person appointed to fill a vacancy on the board shall serve for the unexpired term of the predecessor trustee. Any appointed trustee shall be eligible for reappointment. Any appointed trustee may be removed from his appointment by the governor for just cause.

The board shall elect a chair from among its members every two years. Ten trustees shall constitute a quorum and the affirmative vote of a majority of the trustees present and eligible to vote at a meeting shall be necessary for any action to be taken by the board. The board of trustees shall meet at least ten times each year and will have final authority over the activities of the Trust.

The trustees shall be reimbursed for actual and necessary expenses and loss of income incurred for each full day serving in the performance of their duties to the extent that reimbursement of those expenses is not otherwise provided or payable by another public agency or agencies. For purposes of this section, “full day of attending a meeting” shall mean presence at, and participation in, not less than 75 percent of the total meeting time of the board during any particular 24-hour period.

No member of the board of trustees shall make, participate in making, or in any way attempt to use his or her official position to influence a governmental decision in which he or she knows or has reason to know that he or she, or a family member or a business partner or colleague has a financial interest.

In general, the board is responsible for ensuring universal access to high quality, affordable health care for every resident of the Commonwealth. The Board shall specifically address all of the following:

(1) Establish policy on medical issues, population-based public health issues, research priorities, scope of services, expanding access to care, and evaluation of the performance of the system;

(2) Evaluate proposals from the executive director and others for innovative approaches to health promotion, disease and injury prevention, health education and research, and health care delivery.

(3) Establish standards and criteria by which requests by health facilities for capital improvements shall be evaluated.

Section 7: Executive Director; Purpose and Duties.

The board of trustees shall hire an executive director who shall be the executive and administrative head of the Trust and shall be responsible for administering and enforcing the provisions of law relative to the Trust.

The executive director may, as s/he deems necessary or suitable for the effective administration and proper performance of the duties of the Trust and subject to the approval of the board of trustees, do the following:

(1) adopt, amend, alter, repeal and enforce, all such reasonable rules, regulations and orders as may be necessary;

(2) appoint and remove employees and consultants: provided, however, that, subject to the availability of funds in the Trust, at least one employee shall be hired to serve as director of each of the divisions created in sections eight through twelve, inclusive, of this chapter.

The executive director shall:

(1) establish an enrollment system that will ensure that all eligible Massachusetts residents are formally enrolled;

(2) use the purchasing power of the state to negotiate price discounts for prescription drugs and all needed durable and nondurable medical equipment and supplies;

(3) negotiate or establish terms and conditions for the provision of high quality health care services and rates of reimbursement for such services on behalf of the residents of the commonwealth;

(4) develop prospective and retrospective payment systems for covered services to provide prompt and fair payment to eligible providers and facilities;

(5) oversee preparation of annual operating and capital budgets for the statewide delivery of health care services;

(6) oversee preparation of annual benefits reviews to determine the adequacy of covered services; and

(7) prepare an annual report to be submitted to the governor, the president of the senate and speaker of the house of representatives and to be easily accessible to every Massachusetts resident.

The executive director of the trust may utilize and shall coordinate with the offices, staff and resources of any agencies of the executive branch including, but not limited to, the executive office of health and human services and all line agencies under its jurisdiction, the division of health care finance and policy, the department of revenue, the insurance division, the group insurance commission, the department of employment and training, the industrial accidents board, the health and educational finance authority, and all other executive agencies.

Section 8: Regional Division; Director, Offices, Purposes and Duties.

There shall be a regional division within the Trust which shall be under the supervision and control of a director. The powers and duties given the director in this chapter and in any other general or special law shall be exercised and discharged subject to the control and supervision of the executive director of the Trust. The director of the regional division shall be appointed by the executive director of the Trust, with the approval of the board of trustees, and may, with like approval, be removed. The director may, at his/her discretion, establish a professional advisory committee to provide expert advice: provided, however, that such committee shall have at least 25% consumer representation.

The Trust shall have a reasonable number of regional offices located throughout the state. The number and location of these offices shall be proposed to the executive director and board of trustees by the director of the regional division after consultation with the directors of the planning, administration, quality assurance and information technology divisions and consideration of convenience and equity. The adequacy and appropriateness of the number and location of regional offices shall be reviewed by the board at least once every three years.

Each regional office shall be professionally staffed to perform local outreach and informational functions and to respond to questions, complaints, and suggestions from health care consumers and providers. Each regional office shall hold hearings annually to determine unmet health care needs and for other relevant reasons. Regional office staff shall immediately refer evidence of unmet needs or of poor quality care to the director of the regional division who will plan and implement remedies in consultation with the directors of the administrative, planning, quality assurance, and information technology divisions.

Section 9: Administrative Division; Director; Purpose and Duties.

There shall be an administrative division within the Trust which shall be under the supervision and control of a director. The powers and duties given the director in this chapter and in any other general or special law shall be exercised and discharged subject to the direction, control and supervision of the executive director of the Trust. The director of the administrative division shall be appointed by the executive director of the Trust, with the approval of the board of trustees, and may, with like approval, be removed. The director may, at his/her discretion, establish a professional advisory committee to provide expert advice: provided, however, that such committee shall have at least 25% consumer representation.

The administrative division shall have day-to-day responsibility for:

(1) making prompt payments to providers and facilities for covered services;

(2) collecting reimbursement from private and public third party payers and individuals for services not covered by this chapter or covered services rendered to non-eligible patients;

(3) developing information management systems needed for provider payment, rebate collection and utilization review;

(4) investing trust fund assets consistent with state law and section nineteen of this chapter;

(5) developing operational budgets for the Trust; and

(6) assisting the planning division to develop capital budgets for the Trust.

Section 10: Planning Division; Director; Purpose and Duties.

There shall be a planning division within the Trust which shall be under the supervision and control of a director. The powers and duties given the director in this chapter and in any other general or special law shall be exercised and discharged subject to the direction, control and supervision of the executive director of the Trust. The director of the planning division shall be appointed by the executive director of the Trust, with the approval of the board of trustees, and may, with like approval, be removed. The director may, at his/her discretion, establish a professional advisory committee to provide expert advice: provided, however, that such committee shall have at least 25% consumer representation.

The planning division shall have responsibility for coordinating health care resources and capital expenditures to ensure all eligible participants reasonable access to covered services. The responsibilities shall include but are not limited to:

(1) An annual review of the adequacy of health care resources throughout the commonwealth and recommendations for changes. Specific areas to be evaluated include but are not limited to the resources needed for underserved populations and geographic areas, for culturally and linguistically competent care, and for emergency and trauma care. The director will develop short term and long term plans to meet health care needs.

(2) An annual review of capital health care needs. Included in this evaluation, but not limited to it are recommendations for a budget for all health care facilities, evaluating all capital expenses in excess of a threshold amount to be determined annually by the executive director , and collaborating with local and statewide government and health care institutions to coordinate capital health planning and investment. The director will develop short term and long term plans to meet capital expenditure needs.

In making its review, the planning division shall consult with the regional offices of the Trust and shall hold hearings throughout the state on proposed recommendations. The division shall submit to the board of trustees its final review and recommendations by October 1 of each year. Subject to board approval, the Trust shall adopt the recommendations.

Section 11: Information Technology Division; Purpose & Duties.

There shall be an information technology division within the Trust which shall be under the supervision and control of a director. The powers and duties given the director in this chapter and in any other general or special law shall be exercised and discharged subject to the direction, control and supervision of the executive director of the Trust. The director of the information technology division shall be appointed by the executive director of the Trust, with the approval of the board of trustees, and may, with like approval, be removed. The director may, at his/her discretion, establish a professional advisory committee to provide expert advice: provided, however, that such committee shall have at least 25% consumer representation.

The responsibilities of the information technology division shall include but are not limited to:

(1) maintaining a confidential electronic medical records system and prescription system in accordance with laws and regulations to maintain accurate patient records and to simplify the billing process, thereby reducing medical errors and bureaucracy;

(2) developing a tracking system to monitor quality of care, establish a patient data base and promote preventive care guidelines and medical alerts to avoid errors.

Notwithstanding that all billing shall be performed electronically, patients shall have the option of keeping any portion of their medical records separate from their electronic medical record. The information technology director shall work closely with the directors of the regional, administrative, planning and quality assurance divisions. The information technology division shall make an annual report to the board of trustees by October 1 of each year. Subject to board approval, the Trust shall adopt the recommendations.

Section 12: Quality Assurance Division; Director; Purpose and Duties.

There shall be a quality assurance division within the Trust which shall be under the supervision and control of a director. The powers and duties given the director in this chapter and in any other general or special law shall be exercised and discharged subject to the direction, control and supervision of the executive director of the Trust. The director of the quality assurance division shall be appointed by the executive director of the Trust, with the approval of the board of trustees, and may, with like approval, be removed. The director may, at his/her discretion, establish a professional advisory committee to provide expert advice: provided, however, that such committee shall have at least 25% consumer representation.

The quality assurance division shall support the establishment of a universal, best quality of standard of care with respect to:

(a) appropriate staffing levels;

(b) appropriate medical technology;

(c) design and scope of work in the health workplace; and

(d) evidence-based best clinical practices.

The director shall conduct a comprehensive annual review of the quality of health care services and outcomes throughout the commonwealth and submit such recommendations to the board of trustees as may be required to maintain and improve the quality of health care service delivery and the overall health of Massachusetts residents. In making its reviews, the quality assurance division shall consult with the regional, administrative, and planning divisions and hold hearings throughout the state on quality of care issues. The division shall submit to the board of trustees its final review and recommendations on how to ensure the highest quality health care service delivery by October 1 of each year. Subject to board approval, the Trust shall adopt the recommendations.

Section 13: Eligible Participants.

Those persons who shall be recognized as eligible participants in the Massachusetts Health Care Trust shall include:

(1) all Massachusetts residents,

(2) all non-residents who:

(a) work 20 hours or more per week in Massachusetts;

(b) pay all applicable Massachusetts personal income and payroll taxes;

(c) pay any additional premiums established by the Trust to cover non-residents; and

(d) have complied with requirements (a) through (c) inclusive for at least 90 days

(3) All non-resident patients requiring emergency treatment for illness or injury: provided, however, that the trust shall recoup expenses for such patients wherever possible.

Payment for emergency care of Massachusetts residents obtained out of state shall be at prevailing local rates. Payment for non-emergency care of Massachusetts residents obtained out of state shall be according to rates and conditions established by the executive director. The executive director may require that a resident be transported back to Massachusetts when prolonged treatment of an emergency condition is necessary.

Visitors to Massachusetts shall be billed for all services received under the system. The executive director of the Trust may establish intergovernmental arrangements with other states and countries to provide reciprocal coverage for temporary visitors.

Section 14: Eligible Health Care Providers and Facilities.

Eligible health care providers and facilities shall include an agency, facility, corporation, individual, or other entity directly rendering any covered benefit to an eligible patient: provided, however, that the provider or facility:

(1) is licensed to operate or practice in the commonwealth;

(2) does not provide health care services covered by, but not paid for, by the trust;

(3) furnishes a signed agreement that:

(a) all health care services will be provided without discrimination on the basis of factors including, but not limited to age, sex, race, national origin, sexual orientation, income status or preexisting condition;

(b) the provider or facility will comply with all state and federal laws regarding the confidentiality of patient records and information; (c) no balance billing or out-of-pocket charges will be made for covered services unless otherwise provided in this chapter; and

(d) the provider or facility will furnish such information as may be reasonably required by the Trust for making payment, verifying reimbursement and rebate information, utilization review analyses, statistical and fiscal studies of operations and compliance with state and federal law;

(4) meets state and federal quality guidelines including guidance for safe staffing, quality of care, and efficient use of funds for direct patient care;

(5) is a non-profit health maintenance organization that actually delivers care in its facilities and employs clinicians on a salaried basis; and

(6) meets whatever additional requirements that may be established by the Trust.

Section 15: Budgeting and Payments to Eligible Health Care Providers and Facilities.

To carry out this Act there are established on an annual basis:

(1) an operating budget;

(2) a capital expenditures budget; and

(3) reimbursement levels for providers consistent with subtitle B;

The operating budget shall be used for:

(a) payment for services rendered by physicians and other clinicians;

(b) global budgets for institutional providers;

(c) capitation payments for capitated groups; and

(d) administration of the Trust.

Payments for operating expenses shall not be used to finance capital expenditures; payment of exorbitant salaries; or for activities to assist, promote, deter or discourage union organizing. Any prospective payments made in excess of actual costs for covered services shall be returned to the Trust. Prospective payment rates and schedules shall be adjusted annually to incorporate retrospective adjustments. Except as provided in section sixteen of this chapter, reimbursement for covered services by the Trust shall constitute full payment for the services rendered.

The Trust shall provide for retrospective adjustment of payments to eligible health care facilities and providers to:

(a)    assure that payments to such providers and facilities reflect the difference between actual and projected utilization and expenditures for covered services; and

(b)   protect health care providers and facilities who serve a disproportionate share of eligible participants whose expected utilization of covered health care services and expected health care expenditures for such services are greater than the average utilization and expenditure rates for eligible participants statewide.

The capital expenditures budget shall be used for funds needed for–

(a) the construction or renovation of health facilities; and

(b) for major equipment purchases.

Payment provided under this section can be used only to pay for the operating costs of eligible health care providers or facilities, including reasonable expenditures, as determined through budget negotiations with the Trust, for the maintenance, replacement and purchase of equipment.

The Trust shall provide funding for payment of debt service on outstanding bonds as of the effective date of this Act and shall be the sole source of future funding, whether directly or indirectly, through the payment of debt service, for capital expenditures by health care providers and facilities covered by the Trust in excess of a threshold amount to be determined annually by the executive director.

Section 16: Covered Benefits.

The Trust shall pay for all professional services provided by eligible providers and facilities to eligible participants needed to:

(1) provide high quality, appropriate and medically necessary health care services;

(2) encourage reductions in health risks and increase use of preventive and primary care services; and

(3) integrate physical health, mental and behavioral health and substance abuse services.

Covered benefits shall include all high quality health care determined to be medically necessary or appropriate by the Trust, including, but not limited to, the following:

(1) prevention, diagnosis and treatment of illness and injury, including laboratory, diagnostic imaging, inpatient, ambulatory and emergency medical care, blood and blood products, dialysis, mental health services, dental care, acupuncture, physical therapy, chiropractic and podiatric services;

(2) promotion and maintenance of individual health through appropriate screening, counseling and health education;

(3) the rehabilitation of sick and disabled persons, including physical, psychological, and other specialized therapies;

(4) prenatal, perinatal and maternity care, family planning, fertility and reproductive health care;

(5) home health care including personal care;

(6) long term care in institutional and community-based settings;

(7) hospice care;

(8) language interpretation and such other medical or remedial services as the Trust shall determine;

(9) emergency and other medically necessary transportation;

(10) the full scale of dental services, other than cosmetic dentistry;

(11) basic vision care and correction, other than laser vision correction for cosmetic purposes;

(12) hearing evaluation and treatment including hearing aids;

(13) prescription drugs; and

(14) durable and non-durable medical equipment, supplies and appliances.

No deductibles, co-payments, co-insurance, or other cost sharing shall be imposed with respect to covered benefits. Patients shall have free choice of participating physicians and other clinicians, hospitals, inpatient care facilities and other providers and facilities.

Section 17. Wraparound Coverage for Federal Health Programs.

Prior to obtaining any federal program’s financing through the Health Care Trust, the Trust will seek to ensure that participants eligible for federal program coverage receive access to care and coverage equal to that of all other Massachusetts participants. It shall do so by (a) paying for all services enumerated under Section 16 not covered by the relevant federal plans; (b) paying for all such services during any federally mandated gaps in participants’ coverage; and (c) paying for any deductibles, co-payments, co-insurance, or other cost sharing incurred by such participants.

Section 18: Establishment of the Health Care Trust Fund.

In order to support the Trust effectively, there is hereby established the health care trust fund, hereinafter the Trust Fund, which shall be administered and expended by the executive director of the Trust subject to the approval of the board. The Fund shall consist of all revenue sources defined in Section 20, and all property and securities acquired by and through the use of monies deposited to the Trust Fund and all interest thereon less payments therefrom to meet liabilities incurred by the Trust in the exercise of its powers and the performance of its duties.

All claims for health care services rendered shall be made to the Trust Fund and all payments made for health care services shall be disbursed from the Trust Fund.

Section 19: Purpose of the Trust Fund.

Amounts credited to the Trust Fund shall be used for the following purposes:

(1) to pay eligible health care providers and health care facilities for covered services rendered to eligible individuals;

(2) to fund capital expenditures for eligible health care providers and health care facilities for approved capital investments in excess of a threshold amount to be determined annually by the executive director;

(3) to pay for preventive care, education, outreach, and public health risk reduction initiatives, not to exceed 5% of Trust income in any fiscal year;

(4) to supplement other sources of financing for education and training of the health care workforce, not to exceed 2% of Trust income in any fiscal year;

(5) to supplement other sources of financing for medical research and innovation, not to exceed 1% of Trust income in any fiscal year;

(6) to supplement other sources of financing for training and retraining programs for workers displaced as a result of administrative streamlining gained by moving from a multi-payer to a single payer health care system, not to exceed 2% of Trust income in any fiscal year: provided, however, that eligible workers must have enrolled by June 20 of the third year following full implementation of this chapter;

(7) to fund a reserve account to finance anticipated long-term cost increases due to demographic changes, inflation or other foreseeable trends that would increase Trust Fund liabilities, and for budgetary shortfall, epidemics, and other extraordinary events, not to exceed 1% of Trust income in any fiscal year: provided, however, that the Trust reserve account shall at no time constitute more than 5% of total Trust assets;

(8) to pay the administrative costs of the Trust which, within two years of full implementation of this chapter shall not exceed 5% of Trust income in any fiscal year.

Unexpended Trust assets shall not be deemed to be “surplus” funds as defined by chapter twenty-nine of the general laws.

Section 20: Funding Sources.

20.A: Overview

The Trust shall be the repository for all health care funds and related administrative funds. A fairly apportioned, dedicated health care tax on employers, workers, and citizens will replace spending on insurance premiums and out-of-pocket spending for services covered by the Trust.  The Trust will enable the state to pass lower health care costs on to residents and businesses through savings from administrative simplification, bulk purchasing discounts on pharmaceuticals and medical supplies, and through early detection and intervention by universally available primary and preventive care. Additionally, collateral sources of revenue - such as from the federal government, non-residents receiving care in the state, or from personal liability - will be recovered by the Trust.  Lastly, the Trust shall enact provisions ensuring a smooth transition to a universal health care system for employers and residents.

20.B: Health Care Funding

The following dedicated health care tax will replace spending on insurance premiums and out-of-pocket spending for services covered by the Trust. Prior to each state fiscal year of operation, the Trust will prepare for the Legislature a projected budget for the coming fiscal year, with recommendations for rising or declining revenue needs.

• An employer payroll tax will be imposed comparable to previous spending by employers on health premiums, exempting very small businesses.
• An employee payroll tax will be imposed comparable to previous spending by employees on health premiums and out-of-pocket expenses, exempting low income earners.
• A payroll tax on the self-employed will be imposed, exempting low income earners.
• A tax on unearned income will be imposed to fairly distribute the costs of health care across various sources of income.

An employer, private or public, may agree to pay all or part of an employee’s payroll tax obligation. Such payment shall not be considered income for Massachusetts income tax purposes.

Additionally, the Senior Circuit Breaker Tax Credit for renters and home-owners will be extended to all tax-payers in the Commonwealth.

Default, underpayment, or late payment of any tax or other obligation imposed by the Trust shall result in the remedies and penalties provided by law, except as provided in this section.

Eligibility for benefits shall not be impaired by any default, underpayment, or late payment of any tax or other obligation imposed by the Trust.

20.C: Consolidating Public Health Care Spending and Collateral Sources of Revenue

It is the intent of this act to establish a single public payer for all health care in the commonwealth. Towards this end, public spending on health insurance will be consolidated into the Trust to the greatest extent possible. Until such time as the role of all other payers for health care has been terminated, health care costs shall be collected from collateral sources whenever medical services provided to an individual are, or may be, covered services under a policy of insurance, health care service plan, or other collateral source available to that individual, or for which the individual has a right of action for compensation to the extent permitted by law.

20.C.1: Consolidation of State and Municipal Health Care Spending

The Legislature will be empowered to transfer funds from the General Fund sufficient to meet the Trust’s projected expenses beyond projected income from dedicated tax revenues. This lump transfer will replace current General Fund spending on health benefits for state employees, services for patients at public in-patient facilities, and all means- or needs-tested health benefit programs. Additionally, the Legislature will reduce local aid to municipalities commensurate with the reduced burden of health insurance premiums for municipal employees and contractors.

20.C.2: Federal Sources of Revenue

The Trust shall receive all monies paid to the commonwealth by the federal government for health care services covered by the Trust. The Trust shall seek to maximize all sources of federal financial support for health care services in Massachusetts. Accordingly, the executive director shall seek all necessary waivers, exemptions, agreements, or legislation, if needed, so that all current federal payments for health care shall, consistent with the federal law, be paid directly to the Trust Fund. In obtaining the waivers, exemptions, agreements, or legislation, the executive director shall seek from the federal government a contribution for health care services in Massachusetts that shall not decrease in relation to the contribution to other states as a result of the waivers, exemptions, agreements, or legislation.

20.C.3: Collection of Collateral Sources of Revenue

As used in this section, collateral source includes all of the following:

• insurance policies written by insurers, including the medical components of automobile, homeowners, workers’ compensation, and other forms of insurance;
• health care service plans and pension plans;
• employee benefit contracts;
• government benefit programs;
• a judgment for damages for personal injury;
• any third party who is or may be liable to an individual for health care services or costs;

As used in this section, collateral sources do not include either of the following:

• a contract or plan that is subject to federal preemption;
• any governmental unit, agency, or service, to the extent that subrogation is prohibited by law.

An entity described as a collateral source is not excluded from the obligations imposed by this section by virtue of a contract or relationship with a governmental unit, agency, or service.

Whenever an individual receives health care services under the system and s/he is entitled to coverage, reimbursement, indemnity, or other compensation from a collateral source, s/he shall notify the health care provider or facility and provide information identifying the collateral source other than federal sources, the nature and extent of coverage or entitlement, and other relevant information. The health care provider or facility shall forward this information to the executive director. The individual entitled to coverage, reimbursement, indemnity, or other compensation from a collateral source shall provide additional information as requested by the executive director.

The Trust shall seek reimbursement from the collateral source for services provided to the individual, and may institute appropriate action, including suit, to recover the costs to the Trust. Upon demand, the collateral source shall pay to the Trust Fund the sums it would have paid or expended on behalf of the individuals for the health care services provided by the Trust.

If a collateral source is exempt from subrogation or the obligation to reimburse the Trust as provided in this section, the executive director may require that an individual who is entitled to medical services from the collateral source first seek those services from that source before seeking those services from the Trust.

To the extent permitted by federal law, contractual retiree health benefits provided by employers shall be subject to the same subrogation as other contracts, allowing the Trust to recover the cost of services provided to individuals covered by the retiree benefits, unless and until arrangements are made to transfer the revenues of the benefits directly to the Trust.

20.C.4: Retention of Funds

The Trust shall retain:

• all charitable donations, gifts, grants or bequests made to it from whatever source consistent with state and federal law;
• payments from third party payers for covered services rendered by eligible providers to non-eligible patients but paid for by the Trust;
• income from the investment of Trust assets, consistent with state and federal law.

20.D: Transitional Provisions

Any employer which has a contract with an insurer, health services corporation or health maintenance organization to provide health care services or benefits for its employees, which is in effect on the effective date of this section, shall be entitled to an income tax credit against premiums otherwise due in an amount equal to the Trust fund premium due pursuant to this section.

Any insurer, health services corporation, or health maintenance organization which provides health care services or benefits under a contract with an employer which is in effect on the effective date of this act shall pay to the Trust Fund an amount equal to the Health Trust premium which would have been paid by the employer if the contract with the insurer, health services corporation or health maintenance organizations were not in effect. For purposes of this section, the term “insurer” includes union health and welfare funds and self-insured employers.

Section 21: Insurance Reforms.

Insurers regulated by the division of insurance are prohibited form charging premiums to eligible participants for coverage of services already covered by the Trust. The commissioner of insurance shall adopt, amend, alter, repeal and enforce all such reasonable rules and regulations and orders as may be necessary to implement this section.

Section 22: Health Trust Regulatory Authority.

The Trust shall adopt and promulgate regulations to implement the provisions of this chapter. The initial regulations may be adopted as emergency regulations but those emergency regulations shall be in effect only from the effective date of this chapter until the conclusion of the transition period.

Section 23: Implementation of the Health Care Trust.

Not later than thirty days after enactment of this legislation, the governor shall make the initial appointments to the board of the Massachusetts Health Care Trust. The first meeting of the trustees shall take place within 60 days of the election of trustees to the board.

Massachusetts health reform (known as “Chapter 58”) has been billed as a “model for the nation” and a “blueprint to universal coverage.” This rhetoric has generated expectations that Massachusetts residents of all incomes will be able to get affordable coverage. This hype distracts us from what really has been achieved, what hasn’t, and the strengths and weaknesses of the political strategy that brought us the new law.

Click here to download this easy-to-understand pamphlet by Mass-Care and Massachusetts Jobs with Justice describing how the law works, its successes, and its short-comings.

Free Care Pool
Prior to the passage of Chapter 58, the uninsured had a safety net for seeking medical care, commonly known as the “Free Care Pool”. The Uncompensated Care Pool was created in 1985 as a means of paying for medically needed service provided by hospitals and community clinics and health facilities to uninsured and underinsured low-income residents up to 200% of the poverty line. The Free Care Pool also provided partial uncompensated care to individuals between 200% and 400% of poverty, and aided individuals of any income level in cases of extreme medical hardship or debt.

Health Safety Net
Under Chapter 58, the Health Safety Net was created as a successor to the Free Care Pool. It was implemented on October 1, 2007. Like the Free Care Pool, the Health Safety Net covers medically needed services to those who are not eligible for health insurance and cannot afford to purchase it under the individual mandate. The Health Safety Net has provided care to many who once relied on the Free Care Pool. However, differences between the plans mean that some consumers of subsidized health care are no longer covered under the new plan, or must contribute more fees to their healthcare, which can make needed services less affordable. The Uncompensated Care Pool’s safety net which aided so many has been put in danger by this new law.

Differences Between the Plans - Consequences of Chapter 58:

• Subsidies for low-income residents in Massachusetts are less generous under Chapter 58 than they were for uncompensated care. Prior to the passage of the bill, individuals up to 200% of the poverty line received free care through the Free Care Pool. Under Commonwealth Care, however, only individuals up to 150% of poverty receive care with no premiums.
• The free care pool had no cost-sharing (co-payments and deductibles), while Commonwealth Care does. These fees make care less affordable for some.
• Some have benefited from the new law, as in parts of the state, there were few Free Care providers. Under Commonwealth Care, it is easier for some to find medical care providers.
• The new law cannot be funded, as suggested, through the Free Care Pool. Funds are simply inadequate to achieve this goal.

Other Resources:
Health Safety Net Information

• “Health Safety Net: An Overview,” MassResources.org, July, 2008.

Free Care Pool

• “Massachusetts Uncompensated Care Pool,” Division of Healthcare Finance and Policy, November, 2005.
• “Groups Ask Romney to Postpone Free Care Pool Changes,” Healthcare for All, August, 2005.
• “What’s Next for the Uncompensated Care Pool?” Nancy Turnbull, May 2007.

General Info from mass.Gov

• “Uncompensated Care Pool,” Office of Health and Human Services, 2008.

With health care costs sky-rocketing and employer-sponsored health coverage increasingly burdensome for many businesses, the employer-related provisions in Chapter 58 have done nothing to stop the erosion of an already weakening foundation of employer-provided health coverage. Businesses are trying to shift rising costs onto workers by providing plans with higher levels of employee cost-sharing and employee contributions to premiums and deductibles or by cutting health care benefits completely. In an attempt to slow the erosion of employer-sponsored health benefits, the Massachusetts Health Reform includes two employer-responsibility provisions. However, in practice they have proven easy to evade and ineffective.

In addition, the law has had unexpected consequences for labor relations in the state. A November 2007 survey found that 28% of businesses with uninsured workers plan to hold down wages so that their employees will qualify for subsidies under the law. The reform was supported by some unions, but has been met with stiff opposition by others in Massachusetts. Nationwide, individual mandates have been opposed by many labor groups. John Sweeny, the president of the AFL-CIO, commented that “forcing uninsured workers to purchase health care coverage or face higher taxes and fines is the cornerstone of (Newt) Gingrich’s health care reform proposals. And it is unconscionable that Massachusetts has adopted this misguided individual mandate.” Workers have been saddled with higher fees and the possibility of fines, while the reform’s attempts to involve business in cost-sharing have not been effective.

The Employer Fair Share Contribution is a portion of the law which requires that all employers with more than 10 employees make a “fair and reasonable contribution” towards their workers’ health premiums, or pay a $295 per worker per year fine to the state. While the fine is small compared to the cost of health insurance, the state has defined “fair and reasonable” so that it is easy for employers to evade the fine in practice. Employers covering 25% of their workers or offering to pay 33% of the premium costs for any plan are off the hook. The employer fine was applied to no firms in 2006 and only 500 firms in 2007, raising a paltry $5 million. The expected revenue from the Fair Share program in 2006 alone was $45 million. Firms have avoided the fine by paying a smaller share of premiums for more of their workers, or by spinning off parts of the business to get under the 11 employee mark.

Another provision of the law, the Employer Free-Rider Surcharge, would fine employers whose uninsured workers receive care through public insurance. However, employers who offer a “cafeteria plan,” allowing workers to pay for their own benefits even if employers pay nothing into the plans, are off the hook.

Health care costs and access have been an increasingly troubling problem for both business and labor interests. Between 2000 and 2005, premiums for employer-based insurance rose an average of 9% each year. Nationwide, the percentage of employees covered by their employer plans dropped from 81% in 2001 to 77% in 2005, and the trend continues. If our current ineffective system remains in place, there is no end in sight for rising costs and limited access to care. A single-payer system will reduce costs for employees and for those employers currently providing care to their workers. This coverage would also be portable from job-to-job and during times of unemployment.

Further Resources:

• “Firms Find Way Around State Health Law,” Alice Dembner, December 2007.
• “Mass Has Yet to Collect Fees From Firms for Healthcare,” Alice Dembner, May 2007.
• “Worker’s Health Insurance: Trends, Issues, and Options to Expand Coverage,” Paul Fronstin, Ph.D., March 2006.
• “Changes in Employees’ Health Insurance Coverage, 2001-2005,” Kaiser Family Foundation, October 2006.
• “Chapter 58 of the Acts of 2006: How the Law Affects Employers,” Joint Committee on Healthcare Financing, October 2006.

Chapter 58’s most controversial provision is an individual mandate which requires all uninsured residents to purchase health insurance if an “affordable” plan is available. Those below 150% of poverty get free coverage, those from 150-300% get sliding subsidies, while everyone else (about half of the uninsured) must purchase coverage on their own. The standards for affordability have been criticized by health care advocates.

Governor Mitt Romney publicly supported the individual mandate as a means of eliminating so-called “free riding” in the health care system. Romney claimed that “40% of the uninsured were earning enough to buy insurance but had chosen not to do so” (Wall Street Journal). Patients at 300% of the poverty line and up - those targeted as “free riders” by individual mandate supporters - represent less than 5% of uncompensated care costs in Massachusetts, however.

The Personal Responsibility Movement grew largely out of Newt Gingrich’s attack on welfare receipts, the “Personal Responsibility Act” of his 1994 “Contract with America.” The Personal Responsibility Movement aims to prevent “free riding” by public program recipients, and shift financial burdens onto disadvantaged communities, often through punitive enforcement mechanisms. This idea was revived in the 21st Century in the effort to solve the health care crisis.

An individual mandate is one of the most regressive ways of paying for expanded health coverage, shifting responsibility for health care costs onto individual households. Additionally the penalties for non-compliance are extremely stiff. In its second year residents will be fined roughly $1,000 for being uninsured, similar to the fines for some serious crimes.

Further Resources:

• “New York Times examines Massachusetts Individual Health Mandate,” Kaiser Daily Health Policy Report, November, 2007.

The United States has the highest health care costs in the world, with Massachusetts leading the country in health care costs per person. Premiums have steadily risen at rates above 10 percent per year, more than three times the rate of inflation. These trends are expected to continue in the coming years.

The Massachusetts plan lacks cost controls as well as any new revenue sources that could sustain a significant expansion in access to health care. Initial estimates of the costs and available revenue for the reform were wildly unrealistic. Planning for the law significantly underestimated the number of uninsured in the state. Revenues from the employer fine were estimated at $48 million per year, but fell vastly short, raising no funds the first year, and only $5 million the second year. Almost all funding is coming from the state general budget and federal matching grants: however, subsidies for low-income individuals are coming in hundreds of millions of dollars over budget each year, and the Bush administration is poised to cut federal matching funds.

Failure to control costs not only threatens the sustainability of the reform law, but guarantees continued erosion of employer-sponsored health care for the insured population, and growing strain on state, municipal, business, and household budgets. Even those involved in the creation of the law are beginning to admit the problems with their reform. Massachusetts Senate President Therese Murray admitted that “if we do not constrain healthcare costs, the system we worked so hard to create and implement will collapse.” And John Kingsdale, the executive director of the Commonwealth Connector, announced that “if we have double-digit increases (annually in costs), health reform is not sustainable.”

Massachusetts spends enough to cover all residents with comprehensive health care benefits if we cut out waste in the system and use it for patient care. This will require more fundamental reform.

Further Resources:

• “State Health Plan Underfunded,” Alice Dembner, Boston Globe, March 2008.
• “Healthcare Cost Increases Dominate Mass Budget Debate,” Alice Dembner, Boston Globe, March 2008.”
• Healthcare Myths, Realities,” Alan Sager, Ph.D. and Deborah Socolar, M.P.H., Boston Globe Op-Ed, November 2005.
• “Mass Health Spending Soars to $62.1 billion in 2006,” Alan Sager, Ph.D. and Deborah Socolar, M.P.H., A project of the Health Reform Program of the Boston University School of Public Health, June 2006.
• “Without Cost Control, Universal Coverage Will Fail,” Himmelstein, David, M.D., May 2007

Though the Massachusetts health reform plan received ample media attention as unprecedented legislation, Massachusetts is just one of many states to implement public plans for the uninsured in an effort to achieve universal health coverage. The only original addition in the reform is the individual mandate law. Minnesota’s 2003 HealthRight bill, Tennessee’s TennCare program, and Oregon’s 1989 reform were similarly expected to create landmark change in health coverage among state residents. Washington and Vermont passed such legislation in the 1990’s. These reform attempts were all received similarly by the national media, but none lived up to their claims.

The Massachusetts reform is simply a reincarnation of nearly identical plans that have been tried and failed in numerous other states. However, this fact has been misconstrued by the national media, which has portrayed each attempt as unique and revolutionary. After the reform, Massachusetts was lauded as “the only American state committed to comprehensive medical care.” (CBS, 4/6/06) Minnesota’s reform involved subsidies for the uninsured and a state pool that employers could buy into, and was welcomed as a “plan to solve the health insurance crisis.” (USA Today, 7/1/92) Similarly, Oregon’s health reform in 1989 made headlines such as “Oregon’s Health Law Cure for National Ailment.” (Tulsa World, 10/10/89) Tennessee’s governor claimed his plan would become “a national model” and “the most radical health care plan in America.” (Federal and State Insurance Week) All of these plans, advertised as solutions to the national health care crisis, were eventual failures. Harvard professors David Himmelstein and Steffie Woolhandler note that “each of these reform efforts promised cost savings, but none included real cost controls.”

Tennessee’s massive healthcare reform, TennCare, exemplifies the typical trend of these incremental state reforms. Tennessee planned to cover 300,000 uninsured residents in the first year, expanding to 500,000 in the second, through increased federal funds and expanded Medicaid access for the uninsured. The plan, however, quickly proved unsustainable, with the rate of uninsured in Tennessee dropping from 14.7% to 11.2% the first year, but then rising to 16.4% the following year as funding for new enrollment deteriorated. Studies show that, if left unchecked, TennCare would have consumed 91% of all new revenue growth by 2008, creating an overwhelming fiscal crisis and essentially eliminating the state’s ability to fund other state departments and priorities.

States which implemented “universal” incremental reforms, similar to Chapter 58, between 1987 and 2005 overwhelmingly followed the national trend of increasing percentages of uninsured citizens rather than resulting in decreased rates after the implementation of reforms. Consistently, these incremental reform strategies have faced overwhelming budget constraints due to inadequate cost-control strategies and few effective sources of revenue. These budget crises, coupled with rising health care costs, have prevented incremental reform movements in other states from delivering on promises of “universal” health coverage. Single-payer systems cut the waste out of health care by removing a large portion of the administrative overhead. Without addressing the underlying problem of waste and abuse by the insurance companies, universal health care will not be achievable.

Further Resources:

• “I Am Not a Health Reform,” David Himmelstein and Steffie Woolhandler, New York Times Op-Ed, December, 2007.
• “Struggling to Just Keep TennCare: Terminally Ill Woman Booted Under Changes,” Daniel Connolly, Memphis Commercial Appeal, June 2008.
• “The Impact of Federal and State Funding Levels on Strategic Decisions and How Those Affect Patient Care,” Randy L. Byington, K. Shane Keene, and Douglas Masini, The Internet Journal of Healthcare Administration. 2007.
• “Leading the Way? Maine’s Initial Experience in Expanding Coverage Through Dirigo Health Reforms,” Debra J. Lipson, M.H.S.A., James M. Verdier, J.D., and Lynn Quincy, M.A., December, 2007.

Massachusetts in 2006 passed major health reform legislation (known as “Chapter 58”), designed to provide “universal coverage” to Massachusetts residents of all incomes. However, Chapter 58 has significant weaknesses that prevent it from living up to its hype and is widely recognized as an unsustainable effort over the medium-term.

Documents Available for Download!

• Check out Professor Trudy Lieberman’s series in the Columbia Journalism Review on “Health Reform Lessons from Massachusetts”: Part I, Part II, Part III, Part IV, and Part V.
• Mass-Care’s new Slide Show on implementation of the Chapter 58 reform.
• An Open Letter from Massachusetts Physicians to Senator Kennedy on the Massachusetts model and national health reform.
• An Open Letter from Massachusetts Labor Leaders to President Obama on the Massachusetts model and national health reform.
• Mass-Care and JWJ Pamphlet: ‘Massachusetts Health Reform: Solution or Stopgap?’
• Mass-Care’s original Slide Show on the Massachusetts Health Reform

Background:
Chapter 58 was passed when the federal government insisted Massachusetts reduce the number of uninsured residents using the state’s Free Care Pool, or lose almost $400 million in matching federal grants. The law constituted a compromise between a Democratic state legislature, a Republican Governor, the Bush Administration, and powerful political entities in the state. The legislation thus included progressive provisions to expand public subsidies for health care, conservative calls for “individual responsibility,” and an effective moratorium on reform of the existing health care system to satisfy the health care industry in the state. The bill was introduced and passed within 24 hours with little public scrutiny. Early media coverage lauded Massachusetts for the introduction of the bill, deeming it “the only American state committed to comprehensive medical care” (CBS) and calling the bill an unprecedented piece of legislation that could achieve what “no other state has been able to do” (The New York Times).

What is Chapter 58?
Chapter 58 is a health coverage reform bill, based on a model of state reform that attempts to “plug the gaps” in health insurance coverage through new or expanded public programs, without making significant alterations to the health insurance or health care delivery system. Under Chapter 58 a public subsidy plan called “Commonwealth Care” subsidizes health coverage for residents up to 300% of the poverty level. The bill requires most other residents to purchase health insurance on their own or face penalties (an “individual mandate”). The law attempts to impose a small fine on employers not offering health benefits to their workers, and increased payments to many hospitals and health centers. The law, premised on moving the population into privately managed insurance plans, has also had a dramatic impact on the existing health care safety net in Massachusetts (called the “Free Care Pool”), as well as the hospitals and health centers who treat the uninsured.

Learn More About Chapter 58:

• Similar Reforms in Other States
• Health Care Costs and the Sustainability of Reform
• The Individual Mandate: Origins and Impact
• The Impact on Business and Labor
• The Health Care Safety Net and the Free Care Pool