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  • BIOETHICS FORUM ESSAY

The Devil Can Wait

For a decade or so after the failed Clinton effort at health insurance reform, the subject was considered just too hot and dangerous for politicians to bother with. Recently, however, health reform has seemed possible again, only now the states are leading the way. The most dramatic of the new efforts is the Massachusetts’ health reform plan, which has been hailed as mixing and matching ideas from the left and the right and hammering out a compromise somewhere in the middle – a fundamentally market-oriented plan that also incorporates constraints on the market and subsidies for buyers. The political exchanges were calculated and sometimes combative, and the eventual compromise grudging and qualified (in the end, governor Mitt Romney vetoed one element of the plan and the legislature responded with an override). Still, there’s something new going on in health insurance reform when the Heritage Foundation gives even measured approval to Massachusetts’ Democrats – even if only for being able to follow the lead of the Republican governor. A perspective piece in the New England Journal of Medicine that appeared the week Romney signed the measure into law concluded that “all sides believe they can live with the compromise.”

Maybe. A set of essays we solicited for the current issue of the Hastings Center Report suggests that Massachusetts’ reform effort is very far from winning everybody over. The lead essay, by Jonathan Gruber, a health economist at the Massachusetts Institute of Technology who advised the state on the reform, offers a vigorous defense of the plan, but a couple of the accompanying essays conclude, on the basis of very different arguments and political agendas, that the plan is all but destined to fail.

Some of the criticism, in these essays and elsewhere, is of the mixed and matched pieces. But perhaps the more telling criticism is about gaps in between these pieces. The devil is in the details, and many of the details are just missing. Several commentaries note, for example, that though the reform seeks to make health insurance affordable and even requires all Massachusetts citizens to buy health insurance if it is affordable, what “affordability” means is not specified. In short, not only is the plan a compromise; it also procrastinates. Part of the plan is that there is much more compromising still to be done. On the basis of what’s actually in the reform plan, we may not know yet whether we can all live with it.

But there is still reason for hope, and in fact, the procrastination itself may turn out to be a good thing. James Sabin, coauthor with Norman Daniels of the book Setting Limits Fairly: Can We Learn to Share Medical Resources?, wrote in his essay that he was bullish on the plan because, even though it leaves much to be resolved, it establishes a “promising construct” for working through the many remaining issues “in an open, accountable manner.” The key part of the construct is a board called “the Connector,” whose members are appointed by elected officials but can then function independently – in a manner reminiscent of the Federal Reserve Board. Thus, Sabin wrote, it just may reach the holy grail of making decisions that Massachusetts citizens regard as “disappointing but fair.”

Everybody wants to know whether the plan’s mixed and matched parts provide a model for reform in other states, or even nationally. But it may turn out that the reform’s real genius is that it lifts some of the reform effort away from politicians and give it to someone who can carry it out more effectively.

– Gregory E. Kaebnick

Published on: October 19, 2006
Published in: Health Care Reform & Policy

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