Challenging Dogma - Fall 2007

...Using the social and behavioral sciences to improve the practice of public health.

Tuesday, December 11, 2007

Reforming Massachusetts Health Care Reform – JoAnna N. Sullivan

The Health Insurance Reform Act, Chapter 58 of the Acts of 2006, is entitled “an act providing access to affordable, quality, accountable health care.” It states in its opening paragraph that it is “an emergency law, necessary for the immediate preservation of the public health.” With this mission in mind, the Act requires residents to obtain health insurance, with the option to purchase health care through its facilitator, The Connector (1). The Act created The Connector as a means of providing the mediation between itself and established insurance companies. The purpose of this paper is to explore the flaws of Chapter 58 by utilizing a different paradigm of social and behavioral sciences. This paper outlines the current flaws of Chapter 58 as a means to constructively identify what needs to be improved upon.

By looking more closely at the Act, public health officials will be able to effect positive change. The Act correctly labels itself as a response to an “emergency need,” however its current form only further alienates the uninsured and makes obtaining insurance increasingly difficult. The implementation of the Act threatens to leave many Massachusetts residents stranded without insurance, facing tax penalties, or underinsured.

The Act falls short in achieving its stated purpose of providing affordable, quality health care to all Massachusetts residents. In its current form, it is a power-coercive technique at changing behavior. To achieve the purpose of the Act, it is necessary to consider and include. Power-coercive strategies emphasize political and economic changes. As is well exemplified by Chapter 58, power-coercive changes often include economic sanctions imposed upon individuals for non-compliance. The political changes can also wield moral power, imposing guilt and shame on those who fail to comply, in order to enforce the mandate (2).

While power-coercion may change the institutional reality, it is less effective in changing the behavior of individuals: there is often an overestimation of the ability to change behavior through political mandate. An important characteristic of power-coercive techniques is that the power elite are solely in charge of decision-making that brings major political and economic implications. These decisions are often accepted as legitimate, appropriate political evolutions, but do not necessarily consider the multidimensional realities of the citizenry. The main technique for resistance to power-coercive forms of change is community mobilization in order to illuminate the community’s needs and demands (2).

Seat belt laws are one example of a power-coercive change. Such laws spawn great controversy; many argue in favor of their paternalism, while others object to their encroachments upon personal liberty. Passing laws that regulate behavior raises questions about government’s role in the lives of individuals. Massachusetts has a tumultuous relationship with state laws requiring seat belt use. In 1986, the Commonwealth passed a law mandating the use of seat belts, but voters later repealed it. Then in 1994, the Commonwealth again passed a law mandating seat belts but made it a secondary offense, meaning drivers could only be fined if they were first pulled over for another traffic violation. Under this law, Massachusetts remained the second lowest state for seat belt use (at 65%), only slightly above the lowest state: Mississippi (61% usage rate). It was not until 2006 that the Commonwealth voted to make not wearing seat belts a primary offense, thus making it a legitimate reason to ticket a motorist (3). However after the law was passed, seat belt use rates only rose to 66% (4).

The example of seat belt laws shows the disjunction between a power-coercive regulation and actual personal behavior change. The Massachusetts law did not have much, if any, impact on the increase in seat belt use. Similarly, a power-coercive technique to mandate health insurance is not the most appropriate method. The overarching mandate of Chapter 58 fails to identify and address key impediments to its stated goal of coverage for all residents. There are other ways to more effectively accomplish its goal.

The implementation of such a complex and consequential law necessitates the use of Political Economy Theory. Political Economy Theory appreciates the multidimensional realities of the citizenry and the political and economic issues that have an important bearing on an individual’s actions. An individual’s sociopolitical and economic realities dictate behavior more heavily than outside influences such as government mandates. Political Economy Theory redefines the health coverage inequity as a product of larger social relations: such as socioeconomic status, class, ethnicity, and gender. The problem, here a lack of insurance, is a part of an individual’s trajectory of risk that is shaped by these factors and ultimately dictates (or predicts) a person’s access to care and subsequent health status. Solutions must identify and combat these social, political, and economic risk factors (5).

The Act does nothing to address existing social and economic obstacles. The Act assumes that the uninsured do not have health insurance simply because they don’t have access to it. Chapter 58 provides “access” to this coverage, however, the solution is not as simple as just providing the product and expecting the consumers will follow. The Act does not address issues of cost and cultural, language, or social barriers to coverage and care. There is no appreciation for such differences in either the law or its current implementation. Political Economy Theory identifies barriers to coverage and care.

Many obstacles compel people to remain uninsured. When deciding between food and shelter or health coverage, most, if not all, people choose the former. It is the responsibility of healthcare corporations, especially The Connector, to provide options that do not make this an “either-or” decision but rather allow people to be able to cover themselves and their families. The use of Political Economy Theory more efficiently addresses the obstacles of the population.

Chapter 58 would also benefit from a complete use of Social Marketing Theory. Social Marketing Theory identifies the four “P’s”: product, price, place (accessibility), and promotion (5). The Connector and the Commonwealth have accomplished the first and last Ps: product and promotion, however, they have not worked toward providing the remaining two. Coverage is the product and it is promoted vigorously through television advertisements. However, the price is not controlled nor is it appropriate for the target consumer. Additionally, as discussed in the other arguments, “place” or accessibility and availability are not fully appropriate for the target consumer. Multiple impediments to access to coverage exist, including cultural, language, and political barriers. With a full implementation of Social Marketing Theory, the Act may be a better system of providing coverage to consumers.

Social and cultural limitations of the Act

Chapter 58 is an individual mandate on coverage, which does not distinguish between the individuals who can or cannot afford to buy coverage. The ecological nature of health status and likelihood to be covered are parallel barriers to comply with Chapter 58. The Act must address these barriers in order to more completely accomplish its purposed mission. This section looks at who remains uninsured and their barriers to coverage.

There are systematic aspects of the Act that exclude many of the most needy groups from access. Among some populations, for example Latinos, there is a distinct resistance to buy coverage because of a general fear and mistrust of the government. For individuals who are not citizens, there is a fear that the process of applying for subsidized insurance will be a detriment in the process of obtaining citizenship. Additionally, among this population, the cultural ideal of pride inhibits some from seeking government assistance (10).

Chapter 58 does not address other social obstacles to obtaining coverage. Homeless individuals cannot get coverage without a birth certificate, however, a permanent address is required to receive their birth certificate (3). The media-advertising blitz has not reached many at risk populations so some people are not aware of the opportunities available to them. Also, middle class individuals do not have the means to pay premiums of $200-$900 per month for health coverage through The Connector (before co-payments and deductibles) (10).

For some individuals who qualified for free care prior to Chapter 58, there is resistance to now buy coverage after having previously received free care from some hospitals. Hospitals, especially those that cater to poor populations, lose subsidized funds under Chapter 58 since the Act it requires all residents to have coverage, therefore supposedly negating the need for free care. The free care pool was $600 million of funds allocated to needy hospitals. Now this money is going to subsidize health plans. Some hospitals are still providing free care, especially since there are still a large number of uninsured people in the state. Now the hospitals are not receiving state funds to cover costs left unpaid (10, 11).

The lack of funds is perilous for some health care providers. Hospitals need compensation for the care they give to those who are un- or underinsured. Caritas Carney, a community hospital in Dorchester, is facing major changes or closure if it does not receive more revenue. It has primarily focused on providing free or subsidized care for over 150 years and it received state funding for doing so. However, under Chapter 58, all residents are supposed to be covered thus negating the need for state funding for free care (11). If the Commonwealth is withdrawing money, forcing hospitals to close or reallocate care, more people will be priced out of receiving care.

It is important to use community mobilization techniques to increase the numbers of people who sign up for coverage, as well as to demand appropriate prices. Community mobilization is focused on grassroots activism that fosters community change. In the aftermath of a power coercive political mandate, it is important to empower the community to promote the change that is available. Since many barriers to health are ecological, it is necessary to systematically define the at-risk communities, assess and work with the communities’ established capacity to mobilize, and most importantly understand the community agenda (5). Some grassroots organizations have made important advances in connecting with individuals (10). However, politicians and public health practitioners must better understand the agendas, values, and needs of these communities.

A complete use of Social Marketing Theory can allow Chapter 58 to be more effectively implemented. Social Marketing Theory needs the complete implementation of the four “Ps”: product, price, place, and promotion. The previous arguments show how the lack of the middle two “Ps” (price and place) is stunting the Law. For the homeless and non-English speaking residents, the media blitz is not helpful; therefore the Act has lost its last “P” (promotion) in these populations as well. If there were cost control, easy applications for people, and universal promotion, Chapter 58 would be much more visible and accessible to all Massachusetts residents, thus making it innately more sustainable.

By looking at the barriers to obtaining coverage, the implementation of Chapter 58 would be more appropriate. In order to do so, it is necessary to use a Social Marketing Theory and community mobilization. Social Marketing Theory delineates and addresses the necessary methods to approach such a complex mandate with a disciplinary approach. Community mobilization involves the community and established grassroots organizations that are essential in implementing the Act. This approach is more suitable and comprehensive than the current bottom line power-coercive technique.

Success could leave the State in the red

Chapter 58 is a major political feat in the attempt to accomplish health care for all. However, in its primary stages, there were major oversights that ultimately put the State and the people at risk. The inaccurate numbers of the uninsured and the uneven distributions of wealth of those who have applied for coverage put the State in financial peril. Without the proper numbers, measuring success is extremely difficult.

The reform architects used inaccurate statistics when calculating the number of the uninsured in Massachusetts. Census numbers indicate that 651,000 Massachusetts residents are without insurance; estimates put this number without insurance at 950,000 if undocumented residents are also included. However, the Census number is 65% higher than the figure used by Commonwealth officials when drafting the law and allocating the moneys to implement it. The Massachusetts health reform planners did not account for over 500,000 people because it conducted surveys over the phone, done in English and Spanish, therefore leaving out those people who speak neither of those languages. In addition, it excluded people without a landline, including many young adults who use only cell phones. According to other surveys 44% of phoneless adults are uninsured (7, 8). These particular populations are at high risk for being uninsured.

Now that the law has been implemented, new applications for insurance only constitute one quarter of the people who were previously uninsured. Additionally, job based coverage has decreased substantially since passage of the Act’s, so the increase in numbers of insured may be nullified by the number of people losing coverage from private employers (8). The increase in insured individuals may not be as successful as it appears.

The uneven distribution of people who are signing up for coverage is putting the Commonwealth at financial risk. Ninety-four percent of new enrollees are under 150% of the poverty level and therefore pay only a fraction of the insurance while six percent of enrollees bought private plans with no subsidy (6,9). Costs exceed premiums, violating a key principle of community rating insurance. The Commonwealth is faced with uneven distribution of wealth in its enrollees, which forces prices to rise in order to pay for everyone’s coverage. This will cause an “underwriting death spiral” that will lead to a decrease in healthy, wealthier members who are supposed to offset costs of subsidies. As prices go up, healthier and/or wealthier individuals, who use care less, feel overcharged, and will opt out of coverage because they think it is too expensive and/or they are not at risk. This causes prices to go up again, as an attempt at offsetting the monies lost from the loss of healthier individuals; and so the “underwriting death spiral” continues.

In order to improve upon the Act’s current state, it is important to use Social Marketing Theory. When applying Social Marketing Theory, it is apparent that the product and price are directly affected by the disparity of new enrollees. The State is now burdened by the numbers and types of enrollees because it has done little to universally promote (the third “P”) in order to make the Law sustainable. If Social Marketing Theory were more properly implemented, the State would have a larger pool of applicants and a more equal distribution of need and payers. Chapter 58 is dependent upon the single payments from individuals. However if the majority of enrollees are subsidized, it is difficult to sustain the program. Therefore, it is necessary to reach more individuals to equilibrate the coverage payments.

Prohibitive costs for the individual

Chapter 58 does nothing to control costs. As a power-coercive technique to change the institution, there are no power-coercive mandates for maintaining sustainable costs for the individual. The State made the decision to universally cover its residents first, before addressing costs. There are no programs or corporate initiatives to contain cost. Under this program, the populations most at risk are those being financially punished. By addressing the costs, the Act will be more appropriate for all Massachusetts’ residents. This section outlines the cost needs of the citizenry and the organizational changes necessary for a more proper implementation of the Act.

The populations of people who are signing up pose major problems to the stability and maintenance of the Act. Insurance groups control costs by charging members a similar amount so that the healthy members, who do not use much care, off set the cost of sicker individuals who use more care than the average. A similar equilibrium is sought when supplying subsidized insurance alongside full payer insurance. Individuals who pay the full ticket price offset the amount lost by the company for supplying subsidies to the individuals who cannot pay the full price.

Chapter 58 gives little assistance to the already struggling middle class in Massachusetts. The premiums and co-payments options available are extreme barriers to those in the near-poor group and those in the middle class (8). Faced with either the loss of a personal tax exemption (a penalty of approximately $150 – 250) or possibly $10,000 in health insurance premiums and fees, the struggling middle class may opt to remain uninsured (10). There are often more pressing needs facing individuals, such as food and shelter. This can make the yearly “penalty” of approximately $200 preferable to exorbitant monthly payments.

There is no current incentive for insurance companies to control costs and provide an appropriate, affordable option to the middle class, families, and older consumers (8). Chapter 58, Section 16L solely focuses on quality and cost control for the practitioners (1). However, for a law that was championed for being a provider of affordable insurance to all, it does little to insist on controlling the cost to the consumer. The past year has shown that providers are not controlling prices. As Alan Sager stated, “the law does nothing to control cost (6).” There are no regulations stipulating how prices should be outlined to consumers, and this is the basis of why it is so difficult to effectively achieve the mission of Chapter 58.

Prices are not reasonably appropriate for the consumer. For example, the Connector’s prices are 4.5% higher than comparable private insurance companies. This excess cost goes towards administrative and organizational costs. The establishment of an enterprise like The Connector, in its current state, is just an additional middleman in health coverage. Rather than praise the Act for providing any coverage option to those who are uninsured, a feasible option must be established for those in desperate need of coverage (1, 6). The lack of cost control brings back the need for proper Social Marketing Theory. An important “P” (price) is not being accurately addressed. Without appropriate costs, individuals cannot buy insurance, which leaves the Commonwealth with a disproportionate number of subsidized buyers and legislation that has not completed its mission.

The Connector is not meant to be a profitable corporation, therefore organizational changes must occur in order to better provide coverage. Organizational change demands that a corporation assess and improve group dynamics, encourage and promote shared goals, identify the impediments to change within the organization, and involve the individuals in identifying and implementing new policies. The Connector was created with the purpose of providing affordable coverage to Massachusetts residents (1). However, in its current state, it does not accomplish this. Changes are necessary to ensure that the corporation works towards its established “goals.” This organization is innately not a “normal” corporation that has the luxury of seeking the most profitable means. Rather it was created to provide coverage to residents. It must return to its proposed mission.

Social Marketing Theory reemerges as a necessary part of enacting the Act. The Theory emphasizes price as an important part of implementing a financial intervention. With Chapter 58, there are major financial implications but, unlike other products in the market, healthcare costs have not yet changed with the market. There are no cost controls for healthcare costs, although the market may dictate the need. Without power-coercive techniques to control cost in this power-coercive mandate, costs will skyrocket, further punishing the consumers.

Implications for the Future

Chapter 58 is an ambitious step toward combating the pervasive issue of uninsured members of our community. 200,000 people have become insured under the mandate. However, in order to maximize its effectiveness, there are important changes necessary to improve its current state. There are problematic results of the large disparities in the new realities borne by this Act.

It is improper to continue to handle this law with kid gloves so as to not disrupt the current state of “progress” and blindly celebrate it as a victory. Health care is not progressing; rather the Act further alienates the middle class from coverage and puts the state into financial danger, and perpetuates cultural insensitivity and isolation. Additionally, there will be an ever-growing number of underinsured residents. Underinsurance has detrimental implications on the health care system and economy.

The Massachusetts process has major implications for other states and the nation. It is our responsibility to appropriately, accurately, and effectively carry out the Health Insurance Reform Act, and no longer tolerate excuses about its “acceptability” in the current political climate. There are still changes that can help improve Chapter 58’s efficacy in the Commonwealth. In order to do so, it is essential to open up the public psyche to more creative methods of approaching the situation.


(1) Massachusetts Senate and State of Representatives. Chapter 58 of the Acts of 2006: An act providing access to affordable, quality, accountable health care. Boston, MA. (Accessed 10 October 2007 at

(2) Chin R. and K. Benne. General Strategies for Effecting Changes in Human Systems. (pp. 22-45). In: Bennis, etal, ed. The Planning of Change. New York, NY: Holt, Rinehart and Winston, 1976.

(3) Helman, S. House approves seat belt law. The Boston Globe. 20 January 2006 (Accessed 13 November 2007 at

(4) National Highway Traffic Safety Administration. Traffic Safety Facts: Seat Belt use in 2006. Washington, DC: National Center for Statistics and Analysis. January 2006. (Accessed 13 November 2007 at

(5) Edberg, M. Essentials of Health Behavior, Social and Behavioral Theory in Public Health. Boston, MA: Jones and Bartlett Publishers, 2007.

(6) Zapler, M. State finds universal health care vexing. Oakland Tribune. Oakland, CA. 12 October 2007 (accessed 25 October 2007 at

(7) Kaiser Family Foundation. Medicaid Fact Sheet for Massachusetts and United States. Washington, DC: Kaiser Family Foundation.

(8) Woolhandler S. and D. Himmelstein. Health Reform Failure. Boston Globe. 17 September 2007.

(9) Flanagan J. Massachusetts mandatory health insurance purchase law is no model for California. US Newswire. Washington, DC: 12 October 2007. (Accessed 25 October 2007 at

(10) Dembner A. State boosts effort to reach the uninsured. The Boston Globe. 27 October 2007.

(11) Krasner J. Carney may be sold or shuttered. The Boston Globe. 24 October 2007.

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