Health coverage for all is certainly a goal to which few, if any, Americans would object, even if its realization has run afoul of disagreements over means and methods. By studiously avoiding the word universal (that language killed an earlier bill), and even more deliberately rejecting a single-payer system " two of the reddest flags in the health care debate " the Massachusetts bill may do for the U.S. what the Quebec case is doing in Canada: demonstrate that there is another, workable way of providing coverage without sacrificing dearly-held national principles. But where the prospect of further privatization in Canada is the stick, the Massachusetts bill is a carrot. As Paul G. Ginsburg, president of the Center for Studying Health System Change, noted, Its definitely going to be inspiring to other states about how there was this compromise. He added, For a conservative Republican, this is individual responsibility. For a Democrat, this is government helping those that need help.

Indeed, if the extent of collaboration and compromise alone were the only positive outcome, the bill might prove its worth. The State Senate endorsed it 37-0; only two in the 156-member house voted against it. According to The New York Times, insurers, academics, businesses, hospitals, advocates for the poor, and religious leaders all participated with proposals and input. Liberals like it. The Heritage Foundation likes it. The question is, will it work?

The Premise and the Plan

Massachusetts did not light a fire under the feet of its leaders entirely alone: Washington struck a match when it threatened to eliminate $385 million in federal Medicaid funds if the state did not reduce the number of uninsured people " over half a million at present. And the bill did not take shape overnight, or without a considerable battle among various factions. But what is remarkable is that, rather than settling for simply meeting Washingtons terms, the states leaders took a far more comprehensive approach, one that, in theory at least, both reduces costs and provides coverage for nearly everyone.

The bill contains a fundamental mandate: as of July 2007, all individuals in Massachusetts must have health care coverage. A combination of subsidies, extended coverage, and " for some " penalties is designed to ensure that no one is either left out or permitted to opt out. Employers with more than 10 employees must contribute to employee health care costs; those who do not provide insurance are obliged to pay an annual fee of $295 for each full-time employee.

This last has proven a significant obstacle even now. An original proposal set the charge at $800 per employee. Even with its reduction, and the promise that it would be further lowered as more people became insured, the Governor cancelled that provision, saying that the money is not needed to fund the bill. Democrats, who control the state Legislature, expect to override his veto. And, as The New York Times reported, Bob Baker, president of the Smaller Business Association of New England, said his members generally accept the concept of the fee. The notion of a level playing field, I think from an element of fairness and equity, people are OK with it, he commented. There hasnt been a hue and cry among our members.

A critical assumption underlying the viability of the plan is that, with nearly universal coverage, health care costs actually decline. Employers offering insurance, who actually pay some of the cost of care for the uninsured, will end up paying less. Adding the healthy, who use less care, to the overall pool of the insured, will help keep premiums and deductibles down. One finding, reported in The New York Times, showed that uninsured people with incomes above 300 percent of the poverty level were not, as previously assumed, single mothers without the means to purchase insurance. It turned out it was mostly young males, said Romneys communications director, Eric Fehrnstrom, many of whom make generous salaries. He noted that these men cannot imagine needing health care; when they do, typically for accidents, the state ends up paying for it.

Quibbles and Caveats

It goes without saying that, amid the chorus of enthusiastic and optimistic voices, there are those with reservations about the bill. The Foundation for Taxpayer and Consumer Rights, which describes itself as a non-partisan advocacy group, expressed concern about affordability, given the absence of limits on what insurers can charge. The organization argues, instead, for true universal coverage, using the purchasing power of a public program to pay doctors and hospitals directly.

The most serious, and legitimate, reservations have to do not with intent but with implementation. In an editorial shortly after the bills passage, the Boston Herald noted that the tough job of making health care coverage available for all is just beginning.

Elsewhere in the country, the Eugene (Ore.) Register-Guard commented that Oregonians would do well to let Massachusetts show them the money before trying to replicate the Massachusetts plan here. Others argue that, while Massachusetts efforts are laudable, the real challenge " a complete reform of the countrys health care system " remains unaddressed. And any reliance at all on employer funding meets with disapproval in some quarters. New York Times columnist David Leonhardt wrote that the reality is that a national system will remain a fantasy as long as most employers offer health insurance.

Thus far, the insurance industry itself seems to be taking a wait-and-see approach. A key question, of course, is whether, and by how much, premiums will actually decline under the bills formula. Some believe premiums could eventually be cut in half; others are deeply skeptical. The Massachusetts Division of Insurance has begun shaping regulations for health insurance plans, and the new Commonwealth Health Insurance Connector is to review and approve policies submitted by insurers.

As the Wall Street Journal reported, health insurers are cautious. Marylou Buyse, president of Massachusetts Association of Health Plans, believes it will be difficult to develop affordable policies, because the bill requires that new plans include benefits that are state-mandated for other programs. The bill, she said, does not give insurers much flexibility. That, in turn, others say, may drive insurers to try to cut medical costs, creating further problems for hospitals.

Aetna, on the other hand, expressed enthusiasm for the plans requirements and penalties for the uninsured " the young invicibles, as Aetna terms them " who, the company says, are the greatest drain on the health care system.

When it comes to affordability, a good chunk of the programs cost will come simply from acknowledging the obvious, Leonhardt writes in his column. Massachusetts, he says, spends $350 million annually to pay hospitals for the care of the uninsured. Soon, he continues, it will be able to spend that money helping people buy policies.

Both those who expect complete success and those who are already predicting failure might do well to listen to Massachusetts House Speaker Salvatore DiMasi: Do we know whether this [plan] is perfect or not? No, because its never been done before. At the very least, Massachusetts has made the country sit up and take notice. And perhaps, soon enough, those who have long insisted it cant be done will be drowned out by others asking, Why not?