Massachusetts Insurance Regulator Reflects On The Challenges Of Implementing National Reform

With 21 states suing the federal government over the constitutionality of health care reform and another 15 refusing to participate in the high-risk insurance pools, there is little to suggest that implementation will be any easier than the 15 month battle to pass health care reform. Nobody understands the importance and perils of implementation better than Jon Kingsdale, director of the Commonwealth Connector Authority. In today’s Boston Globe, Kingsdale outlines the lessons learned from implementing near-universal coverage:

1. It’s a campaign: In any successful campaign, continuous progress must be demonstrated and broadly communicated. In Massachusetts, we built partnerships with private and public groups, so that people heard and read about the law everywhere — at Fenway Park, in church, while shopping, or riding the subway. We launched this effort with the Red Sox, and held more than 300 educational forums across the state, the equivalent on a national scale of 15,000 outreach meetings. As a result, voter support for reform has remained high, ranging from 59 percent to 75 percent.

2. Adequate resources: The Massachusetts Legislature appropriately funded implementation with $35 million in the first year; the equivalent on a national scale would be $1.65 billion. Never were shortages of time, expertise, or resources allowed to stand in the way of meeting legislated deadlines.

3. Coordination: Somebody has to be on point to drive implementation across federal agencies and the other organizations needed to execute this undertaking. The Health Connector used multiple consultants and outsourcing strategies, while staffing up, to meet deadlines. With 50 states and far broader legislation, the federal effort will require a Herculean coordination effort.

4. Experiment and evaluate: This effort is new and not everything will go as planned. For example, running an exchange means offering customers what they want to buy, but that’s neither obvious nor unchanging. Massachusetts’ exchange is a learning organization. Key initiatives were launched as pilots, and we have not been afraid to revise them and try again.

5. Transparency: The biggest challenge Washington faces in “helping’’ Americans gain access to care is their distrust of government. Transparency is the antidote: making tough decisions in public; meeting endlessly with employers, unions, insurers, clinicians, and citizens; and both talking and listening out there, in at least 15,000 communities. These are essential to building trust.

6. Harness the market: State exchanges are essentially stores that sell insurance, combining government’s responsibility to protect consumers with a retailer’s need to serve customers. Brow-beating various industries may be good partisan politics, but the Health Connector has worked diligently at creating solid, long-term working relationships.

In other words, the get out the insurance enrollment campaign will probably be more important than the mandate penalties, Congress may have to appropriate more dollars for implementation, and lawmakers have to prepare for the reality that Congress can’t possibly “know enough to specify for every community, the exact design for care that is safe, effective, timely, patient-centered, equitable and sustainable.” They’ll have to allow regulators to experiment!


“The executive branch has 3 1/2 years to work with 50 very different states in bolstering popular support and executing effectively. That will require massive amounts of technical expertise and project management, combined with public outreach and creative communications,” Kingsdale writes, in what I suspect is a great understatement. But Kingsdale himself is not ducking the challenge. He has announced that he will step down from his position in June and while it’s unclear if he’ll come to Washington to lend his Massachusetts experiences to the national effort, he will likely remain an important source of “expertise.” You can read my earlier interview with him here.