Reforming the nation’s health-​​care system is a top leg­isla­tive pri­ority for Pres­i­dent Obama. Over the past few years, Mass­a­chu­setts has reformed its health-​​care system, requiring all state res­i­dents to carry insur­ance or be sub­ject to penalty. Not all agree that this state model should be the basis for a national system. Wendy Parmet, Matthews dis­tin­guished pro­fessor of law at North­eastern University’s School of Law, addresses some of the key ques­tions in the health-​​care reform debate.

Mass­a­chu­setts is the first state in the nation to enact a law requiring res­i­dents to have health insur­ance. Many are won­dering, is health-​​care reform in Mass­a­chu­setts really working?
In most ways, health-​​care reform is working in Mass­a­chu­setts. The number of people without insur­ance has dropped dra­mat­i­cally, and recent studies show that costs have not proven as much of a problem as some feared. Still, the Mass­a­chu­setts model is not per­fect. The state chose to focus on access before addressing pay­ment reform, which means that some dif­fi­cult deci­sions remain. And, Mass­a­chu­setts, like all states, has expe­ri­enced a major drop in state rev­enues due to the reces­sion, which has placed a sig­nif­i­cant strain on reform. Yet, the basic dura­bility of reform is a tes­ta­ment to its overall success.

Do you think that this model should be used as a basis for the nation’s health-​​care reform?
The Mass­a­chu­setts approach has much to offer the nation, which is why many of the bills now being debated in Wash­ington borrow from it. How­ever, it is impor­tant to remember that Mass­a­chu­setts began its reform efforts with a lower per­centage of unin­sured cit­i­zens than exists in most states today, and it has not yet dealt with many of the dif­fi­cult cost-​​savings issues. The fed­eral gov­ern­ment can and should learn from Mass­a­chu­setts, but fed­eral reform should not simply mirror the Mass­a­chu­setts model.

Every indus­tri­al­ized country except the United States has some form of uni­versal or near-​​universal health insur­ance. Is this some­thing that the fed­eral gov­ern­ment is con­sid­ering?
In coun­tries such as Canada, there is a single-​​payer system, which means that cit­i­zens use health insur­ance pro­vided by the gov­ern­ment to obtain care from physi­cians and providers in the pri­vate sector. In other coun­tries, the gov­ern­ment reg­u­lates the insur­ance market and pro­vides some mix of public insur­ance and sub­si­dies for those who oth­er­wise could not afford insur­ance. The latter is what is being dis­cussed in the U.S. There is no doubt that the system we end up with will include a mix of public and pri­vate options. After all, today, some people have pri­vate insur­ance; others, like seniors, have public insur­ance. And while most people obtain their health care from pri­vate insti­tu­tions, others, including many vet­erans, use public health-​​care providers.

It is esti­mated that a new, national health-​​care reform package will cost upwards of $1 tril­lion. Given our fed­eral deficit, can we afford this?
We must deal with health-​​care costs; health-​​care reform needs to tackle that problem. On the other hand, health-​​care costs today con­sti­tute a growing part of the existing deficit, and they pose a major strain on the bud­gets of states, fam­i­lies, and busi­nesses. So, while reform is expen­sive, we can’t afford to do nothing.

How long do you think this reform process will take?
It is likely that we will find out by the end of the year whether reform will be enacted. If it isn’t enacted this year, it may take the elec­tion of a new president.

How will this health-​​care reform affect middle-​​class America?
If reform passes, most middle-​​class Amer­i­cans who have health insur­ance are apt to keep their cur­rent plans. How­ever, they will no longer be vul­ner­able to losing their health insur­ance if they become sick or lose their job. Depending upon how effec­tively reform stems the costs of health care, Amer­i­cans may see their pre­miums rise less steeply than they oth­er­wise would.