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Brown Makes the *Political* Case for Reform

Scott Brown is running on a promise to block the health care bill in Washington. But, as you may have heard, he is not running on a promise to roll back the reforms that Massachusetts implemented three years ago. In fact, he says he supports those reforms.

I had been planning to something about how this proves Brown is an empty suit, as far as substance goes. Remember, the basic architecture of the coverage scheme in Massachusetts is virtually identical to what we'd do nationally if the bills before Congress pass. The big difference--and, yes, it's a big difference--is that the Massachusetts plan didn't really try to control costs, as the national reforms would.

But if you're a conservative who cares more about cost anyway, as Brown claims to be, then you should prefer the national reforms. His position makes no sense, unless he hasn't thought it through.

Then it hit me: Actually, Scott is pretty smart. And he has a lesson to teach national Democrats, particularly those nervous that health care reform will ruin them politically.

It's pretty clear why Brown isn't opposing the Massachusetts reforms: They happen to be popular. In the most recent Boston Globe/Harvard School of Public Health poll, 58 percent of respondents said they supported the reforms while 28 percent said they opposed.

That was down 10 points from the previous year--a year in which, among other things, the state had been forced to cut its budget because of plummeting tax receipts, sending shock waves through the entire health care system. But even with the drop, the signal of support remained unambiguous.

And the numbers were even more lopsided when pollsters asked respondents, straight up, if they wanted to repeal the law. Just 11 percent said they did, while 79 percent said they were against. Polls don't get more lopsided than that.

This makes sense, if you're familiar with what Massachusetts did. Today everybody can now get insurance, regardless of pre-existing conditions.  For people buying on their own or in small businesses, insurance has become much more comprehensive--and the act of buying insurance, through the new Massachusetts Connector, is just a lot simpler. People have more access to care and employers are actually more likely to provide coverage than before the reforms, despite an economy that has gotten worse in the same time span.

To be sure, people in Massachusetts have plenty of complaints. I heard them when I was reporting my article on the state's reforms. But nobody--and I mean nobody--I interviewed suggested rolling back the Massachusetts reforms. (Critics on the left wanted to replace it with single-payer, but that's different.) And even those who were unhappy with elements of the reform said they were, by and large, glad it had become law. As Robert Blendon, an HSPH professor of public health and the poll's co-director, told the Boston Globe

Three years in operation, and with 97 percent of people covered, you have a majority of support, and that is a lesson for Washington.

The lesson is that deliberating over health care reform is messy, unattractive, and unpopular. But health care reform itself is popular once the deliberations are finished. Particularly if a plan can deliver some immediate benefits--a big if, I know, given the slow roll-out of federal reforms--politicians will be better off pointing to those benefits as an accomplishment, rather than having nothing to show for a year worth of effort.

Note: Blendon serves on the board of directors of Assurant, an insurance company. But he's widely considered the pre-eminent expert on public opinion and health care in the U.S., so I trust both his surveys and opinions without reservation.

Update: Over at Politico, Ben Smith quotes Eric Fehrnstrom, a Brown advisor, with an explanation for why the candidate supports the Massachusetts law but opposes its national analogue: 

In Massachusetts, 98% of residents are covered by insurance through our own state reforms. The plan is not perfect, and we need to get costs down, but we have already achieved near-universal coverage. There is nothing for us in a national plan except higher taxes and more spending to finance coverage expansions in other states. It's a raw deal for Massachusetts," he said.

The bolding is Smith's and he's right to highlight that passage: The intent is to make Massachusetts residents think they'll be financing insurance expansions in states like Mississippi that haven't been so forward-thinking on their own. Of course, that's always been the case: States like Massachusetts are often net contributors and states like Mississippi are often net receivers of federal largesse. That's one reason it'd be better to handle this all federally.

It's worth mentioning, though, that the Senate bill actually gave Massachusetts extra Medicaid funding precisely to avoid this problem--that is, in order to make sure it's not punished for having expanded insurance coverage on its own, some time ago. Vermont would get similar treatment for the same reason, thanks in no small part to the efforts of Senator Bernie Sanders.