The Deal in the Details: A shared-sacrifice approach to expanding health coverage
Salvatore F. DiMasi
Speaker, Massachusetts House
Massachusetts House Speaker Salvatore F. DiMasi has a knack for combining seemingly disparate ideas into a workable policy package. Earlier this year, his approach enabled the state to pass a landmark health insurance law.
Massachusetts stood to forfeit $385 million in federal funds unless it came up with a new way of covering the uninsured. Although other lawmakers got out in front of DiMasi on the issue, they started so far apart that few people thought a deal would be possible.
Some advocates promoted a ballot initiative that would have expanded coverage through an assessment on employers. Governor Mitt Romney flatly rejected that idea, believing that more individuals should pay for their own care. Out of these oppositional approaches DiMasi forged a surprising compromise — not by splitting the difference but by insisting that each had some merit.
Under DiMasi’s vision, which ultimately prevailed, everybody had to pay something. Individuals who can afford it will be required to buy insurance, but businesses that don’t provide coverage will also have to pay the state $295 per employee. Requiring sacrifice from everyone made all the difference.
”It was a thorough surprise to the entire health community when it became clear the bill he would move would merge the two approaches,” says John McDonough, of Health Care for All, a liberal advocacy group. “Everybody else seemed to forget the option of trying to do both together.”
Under the new law, the state will impose tax penalties on residents who can afford private insurance but don’t buy it. Private insurance companies, in turn, will receive subsidies for coverage of children and the working poor. And the bill creates a “connector” that will link businesses and individuals with insurance providers. Romney vetoed the $295 assessment on businesses, but the legislature overrode him. “From now on, everyone has to pay or pay a share,” says Cindy Gillespie, counselor to the governor. “That was the piece that made it work.”
DiMasi, 61, deserves the most credit for coming up with that piece. “You gotta make it taste good for everyone,” he says. “Everyone has to see the benefit at the end, or they don’t buy into it, right?”
If DiMasi was able to arrive at a novel approach, he came to it honestly. Despite having served for most of three decades in the Massachusetts House, he had never engaged in health policy in any meaningful way. That left him free, he says, to “take a fresh look” at the issue. The same was true of Patricia Wallrath, his new Health Care Financing Committee chair. “The first thing he said is, ’You don’t have any axes to grind — that’s what I want,’ ” Wallrath recalls.
Serving his first term as speaker, DiMasi wanted to let Wallrath’s committee do its work — in contrast to the chamber’s recent string of autocratic leaders. DiMasi played a traditional leadership role, meeting with lobbyists whose clients might be affected and touting the need for a comprehensive bill to every civic association that would lend him a podium.
But DiMasi also familiarized himself with every comma in the bill. “He sustained the broad vision while immersing himself in every aspect of this initiative,” says Howard Koh, a former state public health commissioner now at Harvard.
DiMasi’s readiness with an easy laugh and a one liner disguises a sharp mind. He makes it his business — and not only with health care — to know an issue “down to the little details that can turn a conference around,” says Patricia Haddad, his education committee chair.
When it came time for the final health care conference committee meeting, DiMasi was able to counter some objections from the Senate side. “Because of his depth of knowledge of the details of the bill,” Wallrath notes, “the speaker could say to the Senate very succinctly this is why we had to do things a certain way. If he hadn’t had that knowledge, I don’t think we would have had as good a bill come out of conference as we did.”
— Alan Greenblatt