I spent 24 hours on a “policy” junket in Boston — talking to some of the policy makers/advocates/rabble rousers who are involved in the state’s health reform. They each seem to come from very different perspectives, all of which made complete sense to me at the time. Maybe that’s what makes a good journalist….but a rotten debate team member.

I started with Dr. Nancy Turnbull, a well-regarded academic at the Harvard School of Public Health (former head of the Blue Cross Foundation) who is also a member of the Connector Board. She is charged with representing the consumer’s point of view on the Board. She conceded that there are gaps in the law, but on the whole, she believes it’s the best the state can hope for right now. Her main focus is on controlling the costs of health care, and — unlike some of her colleagues on the board — she’d like to see a stronger hand of government reigning in expenses. In that way, she’s on the progressive side of things. In another way, she’s also a pragmatist, and while she may at heart favor more government involvement, she believes it is folly to hold out for a complete overhaul, such as a single payer system.

The next day, I spent several hours at Health Care for All (HCFA). This is a consumer organization that is very vested in the health reform law. Leaders from the organization played a key role in getting the law passed (including former Executive Director John McDonough, whom I interviewed in September. He’s now an advisor to Sen. Kennedy.) Staff at HCFA, which has long worked towards universal health care, are unwavering in their position that health reform in Massachusetts has been a success. HCFA points to the 440,000 people who are newly insured under the law, and highlights anecdotes of people who say they owe their health, and in some cases lives, to the health insurance now provided by the state.(It’s worth noting that Health Care for All does get some funding from the private insurance industry, as well as state funding.)

One of HCFA’s tasks is to run a HelpLine . In the last year, five HelpLine counselors took
35,000 calls from consumers trying to navigate the new state health system. (Only about 1300 callers were from Western Mass.) The volume has apparently increased significantly in the last month, which the counselors attribute to the lousy economy and the numbers of newly unemployed.

During the hours I was shadowing the phone counselors, people called wondering where their applications were in the system…..asking for help proving their eligibility for Commonwealth Care …..and getting pointed in other directions. (HCFA gets $127,000 in state funding to provide this service.) While the counselors were certainly upbeat about their work, they admitted that there are glitches in the system — the delays in getting people approved, for instance, and the cumbersome paperwork involved — as well as holes in eligibility, such as people who make just above the income cut-off for Commonwealth Care but can’t afford private insurance. On some occasions, the HelpLine ends up on the receiving end of some pretty angry callers — but there are also many notes tacked up on bulletin boards from grateful consumers who now have health insurance.

I also had a conversation with Lindsey Tucker, who oversees a coalition of diverse stakeholders in health reform. (The ACT coalition, for “Affordable Health Care Now.”) The coalition members come from very different perspectives — hospitals, labor unions, activists, employers — and as a result, the coalition tends to shy away from the most controversial issues (such as payment reform and employer contributions). But Tucker says that’s simply the trade-off to having a diverse group working together towards tweaking the law for the better.David Himmelstein and Steffie Woolhandler My last stop of the day was the Cambridge home of David Himmelstein, who, it’s fair to say, is not on the Christmas card list of Health Care for All, nor are they on his. He is a national activist for a single payer system; he and his wife, Steffie Woolhandler, are both doctors who helped found the group Physicians for a National Health Program. To Himmelstein, Massachusetts health reform has been a virtual disaster. He says many of the low-income patients he sees at Cambridge Hospital, where he’s a primary care physician, are actually doing worse than before, because they now have co-pays under the law, whereas they used to get free care. He also points out that the law has led to severe budget cuts to safety net institutions like his, which care for mostly poor populations.

Himmelstein scoffs at the idea that the federal govermnent would model health reform on Massachusetts, because he believes it’s simply magnifying problems without fixing them. To him, healthcare in America is going to be out of reach for almost everyone unless costs are seriously moderated, and the best way that can be done is by reducing overhead costs — i.e. creating a government-run, single-payer system. He does concede that there could be SOME ways to reduce costs in the current system, but not the ways that most people think. He does not believe that chronic disease management or even prevention reduce costs (although he thinks they’re a good idea!), but rather, he wants to see major change in how payment is doled out (stop paying specialists three times more than family doctors! stop providing financial incentives for unnecessary procedures!). Simply mandating health insurance for everyone, as Massachusetts has done, is not real health reform, he says.

He was willing to credit Massachusetts health reform for providing health insurance to some populations who wouldn’t have had it otherwise — by expanding Medicaid and creating Commonwealth Care for low to moderate income people — but he considers that a drop in the bucket of what needs to be done.

I should add that the folks at Health Care for All, as well as Nancy Turnbull, tell me privately that, sure, they’d be delighted with a single payer system; it’s simply not feasible in this political climate. And given that reality, incremental changes, such as Massachusetts’ health reform, is the best we can hope for. Himmelstein’s response to that pragmatism is a fairly disgusted shrug. Given the signficant popular support in polls for single payer, and the strong record it has had in other countries, it’s clear to him that the only reason politicians aren’t willing to put it into effect is the influence of the corporate and insurance lobbies. What would need to happen to make single payer a reality here, I asked him? Hard to say, he says. Nobody could have predicted the impact of Rosa Parks when she refused to give up her seat on the bus, and look what happened there. Maybe someone will take a similar stand, he says, that could lead to a true overhaul of the health care system.