As we are oft reminded, the devil is in the details. (See, and you thought he was in the White House.) This aphorism springs to mind not because I am working on my tax return but in response to my home state of Massachusetts passing landmark legislation that ostensibly provides for near universal health insurance coverage in the state. While this news may be cause for cautious optimism, I believe that it would be premature to break out the champagne and Cheez-its. There are still many details to be worked out, and only time—and a serious commitment to true health care reform—will tell whether the promise of this legislation will be met. In any regard, in the event that you are unaware of this legislation and its provisions or can’t be bothered because you are too busy playing Tetris on your cell phone, allow me to clue you in, courtesy of the Boston Globe:

Mass. lawmakers pass bill to require health insurance for all

BOSTON—Lawmakers overwhelmingly approved a bill Tuesday that would make Massachusetts the first state to require that all of its citizens have some form of health insurance.

The plan—hailed as a national model and approved just 24 hours after the final details were released—would dramatically expand access to health care over the next three years.

If all goes as the supporters hope, those already insured will see a modest drop in their premiums, lower-income residents will be offered new, more affordable plans and subsidies to help them pay for coverage, and those who can afford insurance but refuse will face increasing tax penalties until they obtain coverage. [full text]

Sounds good so far, right? Exciting. Innovative. Progressive. But here’s where it gets sticky. It remains decidedly unclear—and, indeed, has yet to be determined—what will constitute an “affordable plan� and what the minimum standards of coverage will be. Depending on what the various committees and task forces that will soon be assigned the challenging job of fleshing out the finer details ultimately decide (and how they are swayed by the bevy of lobbyists that will no doubt descend on them like a plague of hungry locusts), it remains to be seen whether this legislation will adequately meet the needs of the citizens of this commonwealth or simply provide universal health insurance coverage in name alone. Steffie Woolhandler and David Himmelstein, both of whom are physicians and associate professors at Harvard Medical School, raise three particular concerns about the Massachusetts legislation, in an article posted on the Common Dreams website:

First, the politicians assumed that only about 500,000 people in Massachusetts are uninsured. The Census Bureau says that 748,000 are uninsured. Why the difference? The 500,000 figure comes from a phone survey conducted in English and Spanish. Anyone without a phone or who speaks another language is counted as insured. The 748,000 figure comes from a door-to-door survey carried out in many languages (including Portuguese and Haitian Creole, common languages in Massachusetts). In sum, the reform plan wishes away 248,000 uninsured people who don’t have phones or don’t speak English or Spanish. It provides no funding or means to get them coverage.

Second, the linchpin of the plan is the false assumption that uninsured people will be able to find affordable health plans. A typical group policy in Massachusetts costs about $4500 annually for an individual and more than $11,000 for family coverage. A wealthy uninsured person could afford that – but few of the uninsured are wealthy. A 25 year old fitness instructor can find a cheaper plan. But few of the uninsured are young and healthy. According to Census Bureau figures, only 12.4% of the 748,000 uninsured in Massachusetts are both young enough to qualify for low-premium plans (under age 35) and affluent enough (incomes greater than 499% of poverty) to readily afford them. Yet even this 12.4% figure may be too high if insurers are allowed to charge higher premiums for persons with health problems; only half of uninsured persons in those age and income categories report that they are in “excellent health.�

The legislation promises that the uninsured will be offered comprehensive, affordable private health plans. But that’s like promising chocolate chip cookies with no fat, sugar or calories. The only way to get cheaper plans is to strip down the coverage – boost copayments, deductibles, uncovered services etc.

Hence, the requirement that most of the uninsured purchase coverage will either require them to pay money they don’t have, or buy nearly worthless stripped down policies that represent coverage in name only.

Third, the legislation will do nothing to contain the skyrocketing costs of care in Massachusetts – already the highest in the world. Indeed, it gives new infusions of cash to hospitals and private insurers. Predictably, rising costs will force more and more employers to drop coverage, while state coffers will be drained by the continuing cost increases in Medicaid. Moreover, when the next recession hits, tax revenues will fall just as a flood of newly unemployed people join the Medicaid program or apply for the insurance subsidies promised in the reform legislation. The program is simply not sustainable over the long – or even medium – term. [full text]

Another concern posed by the legislation is its mandatory nature, complete with financial penalties for those (in the more modest income brackets and above) who are unable or unwilling to comply. Steve LeBlanc touches on this issue in an article in the Boston Globe:

Scrutiny, criticism grow over key section of health care plan

It’s the most innovative — or radical — portion of Massachusetts’ sweeping health care reform bill, but the proposal requiring everyone in the state have health insurance is coming under fire.

The most vocal objections are coming from those who say the new requirement, known as the “individual mandate,” is an unacceptable expansion of the power of the state.

“This is the first time in the country’s history where simply by virtue of living somewhere you are mandated to purchase a product,” said Michael Tanner, of the Cato Institute, a Washington-based think tank.

Supporters of the idea, including Republican Gov. Mitt Romney, say the mandate is a key pillar of the health plan because it forces individuals to take responsibility for their health care….

Romney, a possible candidate for the 2008 Republican presidential nomination, has compared the individual mandate to car insurance. The state requires everyone who owns a car to buy insurance. Massachusetts, under the bill, will require everyone to have health insurance.

That’s a false comparison, according to Tanner. “Driving has always been seen as a privilege that can be revoked,” he said. “This is making me buy a product simply by virtue of breathing.” [full text]

Such mandates raise uneasy questions about the rights and responsibilities of individuals versus the rights and responsibilities of the state. Further examination of this aspect of the legislation is needed. Indeed, I believe the whole bill needs to be critically examined and the citizens of the commonwealth need to remain vigilant and vocal so as to ensure that universal health insurance coverage is truly attained and we do not find ourselves bedeviled with yet another empty and costly promise. Stay tuned.