History of Healthcare Reform in Massachusetts

Over the summer, we are highlighting aspects of our Shared Prosperity Agenda. Our members are sharing their experiences and expertise on Education, Healthcare, Housing, Jobs and Wages, and Progressive Revenue.

This week we are focusing on Healthcare -- Within five years, we want quality, affordable health care covering all medically necessary treatment, a single-payer system similar to Medicare for all. A good first step would be a public option, enabling any resident to pay into an enhanced MassHealth system.

This is part one of our two-part series on Healthcare written by Robin Akerman, Ken Farbstein, Ari Fertig, Shaina Kasper and Enku Kebede-Francis. Special thanks to Ari Fertig and Brian Rosman for this post!

Since the 1980s, the state has tried a series of dramatic health policy endeavors, each of which has influenced national policy. To understand where we are going next, and if we want to enact our Shared Prosperity Agenda, it’s worth taking the time to understand the rich history of the health reform movement here at home. Below Ari Fertig has adapted a version of some of that history by Brian Rosman, Research Director at Health Care For All.


In 1988, under Governor Michael Dukakis, Massachusetts enacted far-reaching legislation establishing universal health coverage. The centerpiece of that law was the policy of “pay or play,” requiring most employers to either “play” – provide health coverage to their workers and families; or “pay” – pay an assessment to the state equal roughly to the cost of providing family coverage, which in turn would be used to provide subsidized insurance.

While the pay or play provisions of the law were never implemented, and ultimately repealed in 1996, the Dukakis law included a number of other policy experiments that influenced national policy, including expanded coverage for children, subsidized coverage for people with disabilities who are working, and funding health coverage for people receiving unemployment benefits. Another provision required all college students to have health insurance, the first instance of a state individual mandate. All of these provisions remain in Massachusetts state law today.

mass_act.jpegEvery decade or so, Massachusetts undergoes an effort like this one to make quality, affordable health care available for all. In 1996, the state overhauled its Medicaid program, renaming it “MassHealth,” with greatly expanded eligibility, a simplified application process, and most members enrolled in managed care systems. The expansion was facilitated by a generous deal worked out with the federal government, using the Medicaid waiver process to allow Massachusetts to claim additional federal funds.

But after the recession in 2001, the number of uninsured grew. While the 1996 Medicaid expansion was successful in driving down the number of uninsured (from around 680,000 to 365,000), by 2004 the number of uninsured people had grown to about 460,000 people.

Second, with the growth of the uninsured came increased demands on the state’s Uncompensated Care Pool, a hospital reimbursement program funded by hospitals, insurers and the state. The program was designed to require minimal state funding, around $30 million. But growing numbers of uninsured patients showing up at hospitals led to increased state funding, reaching $206 million in 2006.

And so, a broad coalition of health care groups, organized by advocacy non-profit Health Care For All, formed to push for coverage expansions. The coalition, known as ACT! (Affordable Care Today), included the state’s hospital association, medical society, community health centers, and numerous influential civic and religious groups. Especially important was the role the Greater Boston Interfaith Organization played. A subset of ACT! gathered some 140,000 signatures to place a reform plan on the ballot, with the intent to force legislative action.

The plan worked. The legislature was interested in having its say – and did not want the ballot initiative to move forward. Governor Mitt Romney was interested in finding a market-oriented approach to covering the uninsured.

Governor Romney’s staff consulted with the Heritage Foundation, a conservative Washington think-tank. They had advised him on a number of ideas that had also informed the early-90s Senate Republican alternative to the Clinton plan, centered around an individual mandate, a structured market for coverage, and sliding scale subsidies for private insurance.

These concerns coalesced in the legislative process that led to enactment of “Chapter 58” with virtually-unanimous majorities in both the House and Senate. Note that it was called Chapter 58 or “Massachusetts Health Reform” – nobody called it Romneycare until later, when it was cast as the state version of the Affordable Care Act, or “Obamacare.”

Governor Romney signed the law, with Senator Edward Kennedy looking over his shoulder, in the historic Faneuil Hall, with Romney campaign TV crews capturing the whole thing for anticipated use in Romney For President TV ads. 


The elements of the law included further expansion of MassHealth (Medicaid), mainly for children; sliding-scale insurance subsidies for low- and moderate-income adults (Commonwealth Care); a reformed individual health insurance market, with an exchange, called the Health Connector, to make it easy to compare and purchase plans; and requirements on employers to offer and individuals to obtain coverage, if it’s affordable.

commonwealth_connector.gifThis of course proved to be the model for the Affordable Care Act, the national story is worth a post unto itself. But what Chapter 58 did not truly address was the issue of costs. 

In summer 2012, the legislature enacted a far-reaching bill, known as Chapter 224 or “payment reform,” aimed at controlling cost growth. The law’s major planks include increasing care coordination, using payment incentives to promote health and efficient care, and investing in public health prevention programs. The law also includes transparency provisions, malpractice reforms, expanded primary care and many other features.

chia_coverage_6-9-14.pngRight now the state is working hard to implement the Affordable Care Act and Chapter 224 simultaneously. A new study suggests that due to the ACA, over 99% of Massachusetts residents have access to some form of insurance.

There is a lot of change coming to the Commonwealth in the way we are shifting paying for care and in the way that consumers will find affordable health care options. Advocates of the Shared Prosperity Agenda must be mindful of these changes and this history as we work to achieve our goals. 


See what the gubernatorial candidates have to say about these and other healthcare proposals here, Lieutenant Governor Candidates here, Treasurer here, and Attorney General here.

See our full statement of Health Care Values here.

Sign our petition here.

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