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July 1, 2006
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Massachusetts takes steps to make healthcare—including behavioral healthcare—available to everyone

Massachusetts has received international attention for its landmark healthcare reform law, which aims to secure healthcare coverage for the state's 550,000 uninsured residents. Major innovations stoked a vigorous debate, such as the mandate requiring every resident to have health insurance and the imposition of assessments on employers with 11 or more employees that fail to offer employees health coverage and make a fair and reasonable contribution to its cost. The governor and state legislators rightly deserve credit for ensuring that more people will have access to needed health services and for advancing the national discussion about access to healthcare.

Under the new law, the state's Medicaid program will expand to cover more people, and sliding scale subsidies will help families earning less than 300% of the federal poverty level (FPL) purchase private insurance. Other reforms will help small employers and workers ineligible for the subsidy connect to more affordable insurance products.

The public discourse on healthcare reform in Massachusetts was not about Republican or Democratic objectives but revolved around the respective roles of governments, markets, and “individual responsibility.” In fact, despite Massachusetts' reputation as a bastion of tax-guzzling, Michael Moore–hugging Democrats, the state is far more politically complex. Most Massachusetts voters are not enrolled in any political party. Democrats do make up more than 80% of our legislature, but Republicans have held the governor's office since 1990. Democrats in the legislature overwhelmingly voted against raising the state income tax the last time the issue was raised, and several Republicans have voted in favor of increased alcohol taxes to support substance abuse treatment services.

To some degree, the spirit of Massachusetts' Puritan forbearers lives on in our state's political culture. Although Massachusetts has gay marriage, voters steadfastly have rejected casinos and slot machines. The state heavily taxes cigarettes, and bars must close by 2 a.m.

Therefore, Massachusetts isn't as “blue” as it is often made out to be. Although the new healthcare law could be seen as a “liberal” concept, it is more a pragmatic solution to a major problem. You could say the people of Massachusetts are pragmatic revolutionaries. Borrowing from the words of the Rolling Stones, we may not always get what we want, but flexibility (rather than reflexivity) may get us what we need.

This pragmatic idealism isn't unique to the state—it's an American tribute. Before and after the adoption of the Constitution, Thomas Jefferson strongly advocated for a Bill of Rights and pushed aside admonitions about its impracticality and difficult implementation, stating, “Half a loaf is better than no bread. If we cannot secure all our rights, let us secure what we can.”

Likewise, Massachusetts mental health and substance abuse providers have approached the behavioral healthcare access revolution with pragmatic idealism. While the state's Medicaid program offers a comparatively generous benefit for mental health and substance abuse services, it is only because advocates worked for years before finally securing passage of a mental health parity law in 2000. Even so, the law is far from ideal. The parity provisions are limited to a specific list of “biologically based” mental disorders, and insurers are required to provide a minimum mandated level of medically necessary coverage for other disorders. In addition, substance abuse has a lower than desired minimum mandated level of coverage. However, we are optimistic about our work to expand coverage for mental disorders not considered “biologically based” and for substance abuse parity. To further promote these efforts, we successfully sought the creation of a standing legislative committee on mental health and substance abuse that has significantly elevated behavioral healthcare's policy prominence.

Simultaneous with these efforts, it was imperative that behavioral health advocates engage the burgeoning healthcare reform debate in the state. Initial proposals offered “stripped down” health plans, providing so-called cost-efficiency by stripping behavioral health coverage and other mandated benefits. We worked aggressively to convince decision makers that this misguided approach would prove penny-wise and pound-foolish, and existing insurance mandates were preserved by the new law.

In addition, on the policy front, under the new law we won approval authority over Medicaid behavioral health benefits for the state mental health commissioner as well as a requirement for the state health secretariat to report to the legislature before making any changes to Medicaid behavioral health programming. On the program front, we achieved the restoration of detox step-down services that had been eliminated during the state's budget crisis in 2003. These victories are part of the larger public-policy debate in which behavioral healthcare is engaged. That mental health and substance abuse care continues to require explicit statutory protection betrays the notion that behavioral health is integral to overall health.