G222

BOSTON -- When Massachusetts passed a pioneering law ensuring health coverage for virtually all its citizens, it punted many critical details to an eclectic group of 10 people.

Over the past year, the group, known as the Connector board, had to wrestle with the tough questions that have stymied efforts at national health-care reform. How much in premiums can low-income people afford? What about middle-class families? Should plans be required to include prescription-drug coverage?

Finding a consensus fell to a motley panel drawn from business, labor, academia and state government. On the liberal end was Celia Wcislo, a 55-year-old organizer with the Service Employees International Union who half-jokingly refers to insurers as "sleazeballs and bloodsuckers." Her frequent adversary was Jonathan Gruber, a 41-year-old Massachusetts Institute of Technology economist who had helped then-Gov. Mitt Romney develop the plan. A Democrat, Dr. Gruber was surprised to find himself on the conservative wing of the board.

The Connector board offered, in microcosm, a look at the collision of interests -- business, labor, medical professionals and needy patients -- that has derailed decades of efforts to reform the U.S. health-care system. When it comes to health-care reform, everyone's second choice, after their own plan, has been the status quo.

INSURING AMERICA

With 45 million people in the U.S. lacking health insurance, states are beginning to unveil plans to broaden coverage. See an interactive map with state-by-state numbers on the uninsured and details on how officials in eight states are addressing the issue.

In Massachusetts, board members did something unusual, finding ways to compromise on some of their most cherished positions and reach common ground. As a result, Massachusetts is poised to become the first state to achieve near-universal coverage. Registration for the new insurance plans began May 1.

Unlike Washington, the Connector compromised successfully because it was expected to, stepping in after a long struggle by state lawmakers to create a plan supported by all major parties. Says Joseph Antos, a health-policy expert at the conservative American Enterprise Institute: "They have a responsibility. They have to produce."

Reaction from the business community is mixed. Many large employers say they're comfortable with the compromises, but representatives of smaller businesses argue the Connector's standards for coverage are too strict and say it should offer more choices of health plans.

In some ways, Massachusetts is an exceptional case. It is a liberal, wealthy state, with just 10% of its population uninsured, compared with 15% nationwide.

And the plan could fail: Skeptics say it isn't tough enough on curbing costs and could ultimately be unraveled by an escalating price tag. No one knows whether the law's combination of carrots and sticks will persuade the uninsured to actually buy coverage.

From the start, Connector board members knew that success wasn't guaranteed. In the early 1990s, the universal-coverage plan spearheaded by Gov. Michael Dukakis collapsed after he left office, amid intense opposition from business interests.

In April 2006, a new plan emerged after months of wrangling between then-Gov. Romney, now running for president, and the Democratic Legislature. A blend of liberal and conservative elements, the law provides subsidized coverage for low-income residents, but offers the coverage through private insurance companies.

And while there are some requirements for employers, the law puts the greater onus on individuals to secure coverage. People who fail to have state-approved insurance by the end of 2007 face penalties that, for some, will soon top $1,000 a year.

Rather than hammer out the details itself, the Legislature left many of the toughest issues to a powerful new authority, the Commonwealth Health Insurance Connector, which was also charged with taking bids from health-insurance companies and then selling those plans to people throughout the state. The Massachusetts law also stipulated that the Connector board be made up of representatives from labor, business and consumers.

It quickly became clear that the board, a mix of appointees and administration members, would be under intense scrutiny. When it held its first public meeting in June, the staff set up 50 chairs but some 300 people showed up. The first battle erupted almost immediately. State and federal officials had allotted $472 million to subsidize premiums for low-income people. How much should this population be expected to chip in?

WHO GETS WHAT?

The Massachusetts health reform aids people in different ways: