Why the ACA resembles the Massachusetts reform

As described in John McDonough’s Inside National Health Reform, in late 2008, Senator Edward Kennedy directed staff of the Committee on Health, Education, Labor and Pensions (HELP) to convene a group of stakeholders to find consensus on a way forward on health reform. (McDonough was a senior advisor to the committee.) This “Workhorse Group” included “representatives of consumer, disease advocacy, business, insurance, physician, hospital, labor, pharmaceutical, and other organizations.” Among the members of the group were Chip Kahn (Federation of American Hospitals), Karen Ignani (American’s Health Insurance Plans), and Ron Pollock (Families USA).

Three avenues for reform were presented to the Workhorse Group:

  1. Constitution Avenue: Elimination of employer-sponsored health insurance, replacing it with either a government, single payer plan or a choice of private plans.
  2. Independence Avenue: Establishment of high-risk pools, subsidization of uninsured, lower-income individuals, and some expansion of Medicaid.
  3. Massachusetts Avenue: Based on the Massachusetts health reform law, a substantial reform of insurance markets, development of exchanges, individual mandate with subsidies.

McDonough writes,

After ninety minutes of talking, we wanted them to choose. We would not let them leave without getting a sense of their preferences.

“How many want to go down Constitution Avenue?” I asked. Zero hands were raised.

“OK, how many want to take Independence Avenue?” I asked. Zero hands.

“All right, how many want to travel down Massachusetts Avenue?” Of the twenty or so in the room, fifteen hands went up.

One sub-group of business representatives (from the Business Roundtable, the National Federation of Independent Businesses, the US Chamber of Commerice, the American Benefits Council, and the National Retail Federation) had not voted for any of the avenues. Asked to come up with another approach, “[t]hey came back the following week but had no alternative avenue to propose.” After their concerns about “Massachusetts Avenue” were aired and addressed, “they choose to stay and participate.”

This was by no means the only process that led to a Massachusetts-style reform, but it has high explanatory power. Given that a key set of powerful interests backed such an approach, it’s not surprising that’s what we got. It’s also why we’re not likely to see dramatic changes to its structure.

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