A Healthy State

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Amidst all the hoopla about the health insurance program just passed in Massachusetts , some people are recalling that policymakers in the state have gone down this road before -- and failed to reach their destination.


Former Governor Michael Dukakis still sounds bitter about how his successor refused to implement his program. "If Bill Weld hadn't screwed it up, we'd have universal coverage in Massachusetts ," he says.


Weld wasn't the only one who was skeptical about Dukakis' 1988 package, which demanded that employers provide health insurance -- or make big payments to the state. As the "Massachusetts Miracle" gave way to recession, state legislators, who had been far from unanimous in support of the idea anyway, suspended the program time and again. Finally, in 1996, it was repealed altogether.


As with so many other attempts at universal coverage, the Dukakis plan simply collapsed of its own weight. "It's widely viewed that it crashed and burned and was a failure," says John McDonough, a former legislator who now runs Health Care for All, an advocacy group.

It would be easy to deduce from this that the new program might similarly be derailed by out-year funding problems. But the 1988 law was not entirely a failure. Far from it. For one thing, several of its provisions remain fixtures on the Massachusetts health landscape to this day. The state then first began to offer health insurance to the unemployed, along with their cash payments. It also allowed the disabled to work without losing their Medicaid coverage -- a model program that influenced a federal law enacted just this past February.


In addition, Dukakis created the nation's first student mandate, requiring college students to have or buy health insurance before they could enroll.


And in the law's very end was the beginning of something else that was important. By the time the employer mandate was finally due to take effect in 1996, legislators had some new ideas about health coverage. They sought a federal waiver to expand Medicaid eligibility and wanted to start a pioneering program to help seniors pay for prescription drugs.


The sponsors of these initiatives agreed to kill the old Dukakis promise of universal coverage in exchange for  support from the business community for an expansion of children's health coverage. This support, in turn, allowed for a big vote in favor of the new programs -- big enough to override Weld's veto.


As a result, nearly half a million more Massachusetts residents receive coverage under Medicaid than was the case a decade ago, even before the new law takes effect.


"One of the elements that was critical in helping us to get that was the fact we were repealing the employer mandate in '96," McDonough says.


History may repeat itself -- Massachusetts could very well fall short again of creating universal coverage, despite all the recent headlines. But if the 2006 law leaves a legacy as rich as the 1988 law, it could be counted a success nonetheless.