Perspectives on an unprecedented law

Perspectives on an Unprecedented Law: Five HSPH experts comment

masshealthturnbull“We are all very concerned in Massachusetts that an adequate safety net of care remain in the system for those who fall through the cracks.” -HSPH Senior Lecturer Nancy Turnbull

A Net With Holes 
“Undocumented immigrants are the biggest group of the uninsured we need to worry about,” says Nancy Turnbull, HSPH associate dean for educational programs and senior lecturer on health policy, and an expert on health insurance regulation and health care access.
No federal funds can be used to finance public coverage for people who are undocumented. Since federal funds support Massachusetts’ subsidized programs, the new law won’t help those who are undocumented and uninsured. How many people this affects is not known.
“In Massachusetts, about 20 to 25 percent of non-citizens don’t have health insurance, but of course not all are undocumented,” says Turnbull. Many of these non-citizens are immigrants with “green cards” who have not yet become citizens.


masshealthblendon“A central problem in the U.S. is that there’s a commitment to the principle of universal coverage, but no agreement on how to pay for it, or on what form it should take.”  -HSPH Professor Robert Blendon

The National Stalemate
HSPH Professor Robert Blendon, who directs the Harvard Program on Public Opinion and Health and Social Policy, has reviewed more than 100 polls of Americans’ views on health care taken over the past 50 years, including his own polls. There have been cycles of interest in reform and universal coverage, he notes, but then no change.

“Efforts tend to fall apart due to fundamental disagreements over the role of government, between those who believe in it taking an active, central role and those who think government will make health care worse and who want to see a range of private, commercial choices.”

Here’s where leadership comes in, Blendon believes. “It’s extraordinary in Massachusetts that they found the compromise between these fundamental differences. It’s a lesson that if anything is going to succeed on the national level, it’s going to take a huge compromise.”


masshealthswartz“In the United States, one in ten of all middle-class adults is uninsured.” -HSPH Professor Katherine Swartz

The Clout of the Middle Class
Although 2/3 of the uninsured are in lower-income brackets, a surprising 1/3 are middle class, with household incomes above the median, which in 2006 was $48,200, says Katherine Swartz, PhD, HSPH professor of Health Economics and Policy.

One reason is that the self-employed and others shut out of group insurance face high premiums when they buy as individuals. The Massachusetts law merges the individual and small-employer markets into one large pool with greater purchasing power.

Swartz served on a commission that was asked to study the impact of this part of the proposed law before it was implemented. “We reported that premiums will be 14 to 15 percent lower for the individuals, and increase only 1.5 percent for those in the small-employers group,” says Swartz. “The idea is that premiums will be driven down as more of the healthier, younger, entrepreneurial individuals join the insurance pool.”


“This law won’t get absolutely everyone covered, but deserves a full chance at implementation.”

-HSPH Lecturer John E. McDonough

Why We Should Care
John E. McDonough, executive director of Health Care for All and an adjunct lecturer at HSPH, says there are many reasons Americans all across the nation should be concerned about the huge numbers of people who are uninsured. He offers a few.

The first is the humanitarian argument: there is ample evidence that those without insurance live sicker lives and die earlier. Reasons two and three are pragmatic and cost-conscious. Millions resorting to “free” care destabilize the price of coverage, since the high costs of such care must be borne by everyone. It’s an inefficient way to care for the uninsured.

Finally, look at the rest of the developed world, McDonough urges. Countries like Switzerland, Australia, Germany and the U.K. spend one-half to two-thirds of what the United States does, yet their citizens still get excellent health care. All these nations, he adds, have longer life expectancies than we do.


masshealthhagar“Each stakeholder who came to the table had a great deal to gain and something great to risk.”
-HSPH Instructor Christie Hager

A Model of Shared Responsibility
As the state rolls out implementation of its ambitious plan, there has been some quibbling over whether business should do more or insurance companies should earn less. “When I see tension like that, I’m not troubled,” says Christie Hager, chief health counsel to Massachusetts Speaker of the House Salvatore DiMasi and an instructor at HSPH in public health practice. With DiMasi, Hager helped hammer out the text of the new law.

“It’s inherent in a political process with so many moving parts. Though each group may feel the burden is greater on them, in the end, it all levels out. We are all committed to a successful outcome.”


For the full text of the Massachusetts law known as Chapter 58 of the Acts of 2006, see

Consumer information on finding insurance plans is on the Commonwealth Connector site at

Health Care for All supports Massachusetts’ most vulnerable residents as leaders in public policy, advocacy, education, and consumer service.

Visit and see the group’s blog at