To some extent, the Affordable Care Act (ACA) is based on the “Massachusetts experiment,” the health care legislation passed by the state in 2006, leading politicians on both sides of the political aisle to claim it as a success or failure. Supporters assert that the legislation resulted in nearly universal health insurance coverage in Massachusetts. Detractors point out that the quality of coverage may be suboptimal and its costs are exorbitant. Both sides have overstated their cases.Massachusetts health care reform was evolutionary, not revolutionary. In 1985, the state established a “free care pool” paid for by profitable facilities to support the safety net hospitals. Hospital rate deregulation in 1991 resulted in a cost crisis, leading both conservative and liberal politicians in Massachusetts to cooperate on legislation. In 2006, a Republican Governor, a Democratic Speaker of the House, and a Democratic President of the State Senate collaborated to develop Massachusetts health insurance reform. The Republican Governor insisted on a proposal originally written by Stuart Butler, PhD, of the conservative Heritage Foundation (and a JAMA Forum contributor), which included an individual mandate to purchase health insurance. Butler said, “If a young man wrecks his Porsche and has not had the foresight to obtain insurance, we may commiserate, but society feels no obligation to repair his car. But health care is different. If a man is struck down by a heart attack in the street, Americans will care for him whether or not he has insurance.”
Although it is true that the legislation resulted in near-universal health insurance coverage in Massachusetts, including 98% of the state’s population and nearly 100% of children, baseline rates of insurance were high before the law went into effect. In 2007-2008, when the law was just being implemented, uninsured rates in Massachusetts were only 5% at a time when up to 25% of the population of California, another progressive state, was uninsured.
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