Healthcare Bill Is a Vital Sign of Bipartisan Progress

Two miracles took place in Massachusetts last week.

First, the Legislature approved the nation’s most ambitious effort to expand access to health insurance.

Second, the plan emerged from a process of creative bipartisan collaboration between Republican Gov. Mitt Romney and an overwhelmingly Democratic Legislature.

At a time when Washington is locked in partisan warfare on almost every front and has done little to reverse the declining access to health insurance nationwide, it’s difficult to say which of Massachusetts’ achievements is more remarkable. Both should inspire not only other states but the federal government as well.

The Massachusetts health plan “is an intriguing, innovative, different experiment that really demands attention and respect from folks around the country,” said John E. McDonough, a former state legislator who now directs Health Care for All, an advocacy group. “It is an amalgam of left and right approaches that I have not seen.”

The legislation, which Romney plans to sign this week, aims to provide health insurance to 95% of the roughly half a million state residents without it.

As McDonough suggests, the plan’s secret is that it blends ideas favored by liberals and conservatives into a comprehensive attack on the stubborn problem of the uninsured (who now number nearly 46 million nationwide).

The plan’s foundation, originally proposed by Romney, defines an important principle of joint responsibility between individuals and government to ensure coverage.

The plan would require all Massachusetts residents to buy health insurance, the way states now require all drivers to purchase car insurance. But the state would cover all the costs for families whose incomes are below the federal poverty level (about $20,000 annually for a family of four) and subsidize premiums, on a sliding scale, for those earning up to three times that amount.

The plan would establish an innovative insurance exchange that would offer individuals and small businesses a variety of policies to purchase. It would provide health insurers more leeway to offer stripped-down, less expensive policies, especially for young people. It also would expand government-provided Medicaid for children in working-poor families and would require employers that don’t cover their workers to contribute to the cost of the state premium subsidies.

That thumbnail hints at the plan’s brilliant political balancing.

The package advances many ideas dear to conservatives. It enshrines the conservative value of individual responsibility by requiring everyone but the poor to contribute to their own coverage. It would provide that coverage primarily through the private marketplace, not government programs.

It would test (for young people, at least) the conservative belief that insurers will create much more affordable health policies if extensive state mandates to cover specific treatments are loosened. And starting in 2008, it would link payments for healthcare providers to the results they produce for patients -- an idea gaining ground in both parties.

“The Democratic rhetoric has been about getting insurance for everyone, but their answer is always taxes and government takeover,” Romney said in a characterization that Democrats, of course, dispute. “We took the ideal of insurance for everyone but applied Republican principles: Reform the market, help those who truly can’t afford to buy it themselves.”

But the plan advances just as many priorities of the left. It includes a significant government role through the subsidies to poor and working-poor families. Though the initial payment would be modest ($295 a year), the legislation would require employers not currently providing insurance to contribute to care for their workers. Most important, through the new state exchange it would protect the idea that insurance should share risk between the young and old, the healthy and sick.

John Sasso, a veteran Democratic political strategist who lobbied on the bill for healthcare providers, said Romney, a likely GOP presidential candidate in 2008, deserved much credit for the breakthrough. “He put ideas on the table ... then he handled the politics well,” said Sasso. “He was working constructively ... to get something done.”

Much could still go wrong. The immediate risk is that coverage would remain too expensive for the uninsured who earn too much to qualify for the public subsidies. The plan would exempt individuals from the mandate if they couldn’t find affordable coverage.

The longer-term danger is that the program might grow unaffordable not only for individuals, but for the state, if healthcare costs keep rising at their current rate.

The initial projection is that once the program is fully running, the premium subsidies for low-income families will cost $725 million a year. The Bush administration pitched in by allowing the state to apply federal Medicaid funds toward that bill. But if premiums rise faster than expected, the state still might be unable to afford sufficient subsidies to keep insurance within reach of lower-income families -- especially since it has not dedicated any specific source of revenue, such as a cigarette tax hike, to the plan.

Those threats are real. But the Massachusetts plan has created a structure supple enough to respond to the challenges that emerge if the state’s future political leaders show the flexibility demonstrated by Romney and state Democratic leaders, such as House Speaker Salvatore DiMasi.

Romney, as his comments above show, hasn’t renounced partisanship. Neither have Massachusetts Democrats. But both sides overcame partisanship to reach a productive agreement. That’s the most important lesson in the Massachusetts breakthrough.

“In the private sector,” said Romney, a former management consultant, “you don’t get anything done inside an organization by battling. You look for consensus and coalition-building, and that’s what we have had to do here.”

*

Ronald Brownstein’s column appears every Sunday. See current and past Brownstein columns on The Times’ website at latimes.com/brownstein.