Viewpoint: Medical Mystery Tour


Charles Atkins is…excited. As welfare commissioner for the Commonwealth of Massachusetts, Atkins is charged with implementing key sections of the Health Security Act of 1988, a new law that aims to provide health insurance to every man, woman, and child in the state—and to pay for it with pounds of flesh carved out of nearly every employer.

"This is very exciting," he says. "Nothing like it has been done before. My people have to get it up and running, and we're essentially doing it from scratch. That's an exciting prospect."

Mm-hmm, I say to Atkins, but aren't you confused by this law? Everyone else I speak to is annoyingly vague about it all: if I ask about its provisions, my interlocutor's voice grows indefinite, his answers hesitant: "I'm pretty sure…," he'll begin, or, "Well, to the best of my understanding…"

Atkins smiles happily. "Don't you see? That's the exciting thing. We'll figure it out as we go along! With legislation like this, if we'd had to work out every detail in advance, it would never have made it."

Still, helpfully, he offers to sort out any points I've gotten stuck on. So I ask him what rules govern an employer whose employee is already covered by a spouse's insurance plan. Whereupon Atkins plops right in it: "I'm pretty sure that he's off the hook if—well, my understanding is the employee gets the option of which policy to go with."

His aide chimes in, "But during a job interview, he can't ask if the employee's already insured, so he wouldn't know if he's off the hook or not."

Atkins pauses, then gives me that God-isn't-life-great smile again. "See how exciting this will be? We'll set up this program, and try different things out, and if something doesn't work we can always change it later!"

A law that went through six major revisions and, in final form, runs to 105 pages is not easily summarized. Its elements are convoluted, its requirements onerous, its side effects unknown, and its costs—always the hallmark of a Michael Dukakis initiative—will be staggering.

The Health Security Act, actually, is drafted on the Certs model: two, two, two bills in one. The boring part is a package of hospital financing and cost-containment measures. (That's "containment" of the sort Chernobyl made famous.)

The sexy part—the part Dukakis touts when he campaigns in Fargo and Tallahassee—mandates health insurance for every Massachusetts resident by the simple expedient of ordering business to pay for it. En brêf, it works like this:

Companies with more than five employees will be required to spend at least $1,680 per employee on health insurance. Employers who don't will be fined that amount by the state. ($1,680, of course, is an arbitrary number; as with any other tax, nothing will stop the legislature from periodically hiking it.)

Firms must also pay an additional sum into a pool to be used by a newly created state agency—another Dukakis hallmark—to purchase health insurance for the unemployed or otherwise uninsured. In theory, anyone from a hobo who sleeps in doorways to an actor hungry for a role will be able to go to the Department of Medical Security and buy medical insurance, paying—are you ready?—as much as he can afford.

This legislation is going to cost the Commonwealth of Massachusetts—well, let's get it directly from Governor Dukakis, speaking on the eve of signing the health insurance bill into law: "The cost to the Commonwealth's treasury? Well, we estimate…somewhere between $600 million and a billion. I think. Something like that…I don't know what the numbers are. It's hard to estimate."

In fact, the nonpartisan Massachusetts Foundation for Economic Research estimates that "the true cost of the…law would range from $1.7 to $2.0 billion a year by 1993."

But the true cost of the Health Security Act of 1988 is not measured in dollars but in its effects on Massachusetts's struggling entrepreneurs. Hiring a sixth low-wage employee, remember, is going to cost employers a fortune: $1,680 x 6 = $10,080 in mandated costs over and above the salary of the new hire. How many modest firms will consequently forbear from hiring that sixth employee? How many will not start up in the first place? Or not start up in Massachusetts? Or not stay in Massachusetts?

No wonder New Hampshire Gov. John Sununu declares the Bay State's experiment is "good news for New Hampshire's economy." Massachusetts has hemorrhaged more than 96,000 manufacturing jobs since 1984, and Sununu is convinced the new law will only intensify the flow of businesses heading north.

Ah, but by the time that happens, Michael Dukakis means to have taken up residence in a large white mansion far from Beacon Hill. And then, it'll all be somebody else's problem.

Jeff Jacoby is the Boston Herald's chief editorial writer.