Posted on August 11, 2008

Copy Massachusetts' health reform? Not so fast, researchers say


For full text of the study:

Aug. 11, 2008

David Himmelstein, M.D., (312) 782-6006
Benjamin Day, (617) 777-3422,
Mark Almberg, (312) 782-6006,

Citing the failure of seven state-based health reforms over the past two decades - initiatives that bear a strong resemblance to the Massachusetts health reform of 2006 - a group of Massachusetts-based researchers cautions that early declarations of the latter’s success may be premature.

In an article titled “State Heath Reform Flatlines,” published in the most recent issue of the International Journal of Health Services, three researchers, two of whom teach at Harvard Medical School, examine the experiences of earlier reforms in Massachusetts, Oregon, Minnesota, Tennessee, Vermont, Washington state and Maine. The plans were enacted from 1988 through 2003.

All seven reforms, which when launched were widely trumpeted by political leaders and leading newspapers as breakthroughs in providing universal health care, were based on the expansion of private insurance coverage, the authors say. But in each case the plan had little impact on the state’s number of uninsured persons and produced no sustained improvements in delivering care.

Dr. David Himmelstein, a co-author of the study, said the 2006 Massachusetts reform appears poised to follow the pattern of the 1992 Tennessee plan, which featured a large expansion of coverage under a Medicaid-like program. “In Tennessee, the number of uninsured dipped for two years, then rose to levels higher than ever,” he said. “And the plan proved to be unaffordable in the long term.

“According to the latest figures on Massachusetts from the National Health Interview Survey,” he continued, “the uninsurance rate has fallen by only 2 percent, from 7.7 percent to 5.8 percent, since the reform was passed, while the plan is already $147 million over budget.”

Himmelstein, who is an associate professor of medicine at Harvard and a primary care physician in Cambridge, Mass., said the seven failed plans incorporated virtually all of the reform elements being advanced today by leading Democrats, including Sen. Barack Obama. The problem, he said, is that such reforms leave the private health insurance industry in a dominant position.

“Politicians like to claim they’ve passed bold health reforms, but they’re afraid to rock the private insurance boat,” he said. “So they keep pushing gussied-up versions of reforms that have failed time after time. Our health care system is sick to death, and our politicians keep prescribing placebos.”

The authors note that all of the failed plans included expansions of Medicaid or similar programs for the poor and near-poor. Three states’ reforms (Massachusetts in 1988, Oregon in 1989-1992 and Washington state in 1993) included mandates requiring employers to cover their workers, and the Massachusetts and Washington plans also included an individual mandate on the self-employed.

The authors analyzed Census Bureau data on uninsurance rates in each of the seven states. Massachusetts’ uninsurance rate rose from 7.2 percent to 9.7 percent in the three years after the passage of then-governor Michael Dukakis’ universal health care reform in 1988. Uninsurance went from 14.1 percent to 14.7 percent in the three years after implementation of Oregon’s universal health care reform in 1993. The percentage of residents lacking coverage in Washington state increased from 10.7 percent to 11.6 percent in the three years after passage of its universal health care initiative.

Similar patterns occurred in Vermont and Maine. Tennessee’s program (which included the largest Medicaid expansion) was probably the most successful, dropping the share of uninsured in the state from 12 percent to 9 percent in its first year, before a rebound to 14 percent by year three. (See charts in links below.)

All of the plans eventually “flatlined,” or died quiet deaths, the authors said.

According to Benjamin Day, executive director of Mass-Care, a health care advocacy coalition based in Boston, “It’s easy to build political consensus for expanded health coverage. But experience shows that you can’t achieve universal coverage at an affordable price unless you throw out the insurance companies with their massive overhead and profit, and replace them with a more efficient single-payer national health insurance program.

“Senator Obama should learn this lesson,” Day said. As for Sen. John McCain’s health care proposals, “they are so obviously unworkable that it’s hard to take them seriously.”


The text of the study is available in PDF to the press at

Additional charts in PowerPoint format are available at

“State Health Reform Flatlines,” Steffie Woolhandler, MD, MPH; Benjamin Day; and David U. Himmelstein, MD. International Journal of Health Services, Vol. 38, No. 3.

Physicians for a National Health Program, a membership organization of over 15,000 physicians, supports a single-payer national health insurance program. To contact a physician-spokesperson in your area, visit or call (312) 782-6006.