Massachusetts’s 2006 healthcare reform plan, often cited as a model for the nation, is sailing through choppy waters. Governor Deval Patrick is keeping it afloat by throwing away the lifeboats: public hospitals and clinics. Freighted with tax-funded windfalls that brought private insurers and hospitals on board, the reform has proved far more expensive than politicians forecast–costing the state $1.3 billion this fiscal year, according to the state’s report to its bondholders.
Yet despite the threat of a $1,068 fine for being uninsured, hundreds of thousands remain uncovered in Massachusetts, and the number of uninsured patients showing up at hospitals and clinics has fallen by only one-third. Moreover, according to surveys one in five state residents (including many with insurance) cannot afford care, and those directly affected by the reform are more likely to say it has hurt than helped them.
High costs and skimpy coverage are in the reform’s DNA; private insurers drafted its blueprint, cementing their dominant role. As a result, the plan forfeited the savings on bureaucracy that a single-payer plan could realize–an estimated $7.8 billion annually in Massachusetts alone. The public-plan option that Massachusetts’s reform offers to the near-poor hasn’t trimmed bureaucracy–a warning that this option, pushed as a compromise at the federal level by erstwhile single-payer supporters, would yield scant savings. Indeed, Massachusetts’s reform has actually increased bureaucratic costs; the new insurance exchange (similar to that touted by President Obama and Senate Finance Committee chair Max Baucus) has added 4 percent to insurers’ already high overhead. Promised savings through prevention, care management and computerization (also mainstays of Obama’s plan) haven’t materialized. Consequently, much of the new coverage has come with unaffordable out-of-pocket costs. And cost overruns have drained state funding for care of those who remain uninsured.
Now comes a recession, drying up jobs and private coverage, along with the tax revenues needed to subsidize coverage for the newly uninsured. Facing a yawning budget deficit and desperate to stay the course on the 2006 reform plan, Patrick has slashed funding to safety-net providers such as Cambridge Health Alliance (CHA) and Boston Medical Center (BMC) (né Cambridge City and Boston City Hospitals). (Disclosure: we practice at CHA and teach at Massachusetts General Hospital.)
At CHA–a Harvard affiliate that operates three public hospitals, twenty-one community clinics and more psychiatric beds than all of Boston’s big teaching hospitals combined–the cuts will shutter one hospital, six clinics, the area’s only inpatient detox unit and nearly half of the psychiatric wards. Even before these closures, suicidal patients often spent days in ERs awaiting a bed.
These cuts follow a national pattern of responding to fiscal crises by defunding hospitals that care for the poor. Chicago’s Cook County healthcare system recently suffered massive cuts, including half of its outpatient clinic doctors. Now women with abnormal Pap smears can’t get follow-up appointments, and mammograms aren’t available. In Los Angeles, the only hospital serving a huge area of the central city shut its doors; LA’s surviving public hospitals and clinics face a $750 million shortfall.