The Troublemaker in Health Care

The Troublemaker in Health Care

A key force behind passage of the Massachusetts health reform law of 2006—the first state legislation to require all adults to have health insurance coverage—John McDonough, Dr.P.H. ’96, defines himself as “a troublemaker. I try to help draw attention to health system problems and help to organize and lead efforts to correct them.”

McDonough directs Health Care for All, a Boston-based consumer advocacy organization that was deeply involved in passage of the 2006 law and is now helping to implement it. (The law calls for 90 to 95 percent of the state’s uninsured to have health care coverage by 2009.) A Massachusetts state representative for 13 years and the author of two books, including Experiencing Politics: A Legislator’s Stories of Government and Health Care, McDonough knows first-hand that “you can have a great impact and get a lot done on the inside, and you can have a great impact and get a lot done on the outside as well.” He spoke to Findings about the current state of health care in America.

Findings: Where do things stand with the Massachusetts health reform law of 2006?

McDonough: Since the law was signed last April 12, more than a hundred thousand people who were uninsured on April 12 have affordable quality health insurance today. We still have a long way to go. Overall, the project is proceeding well.

The issue of health care coverage is looming large. Do you think it’ll be solved at the federal level, or by individual states, or by consumer groups like Health Care for All?

All of the above. Right now we’re in a multistage health reform wave that’s just unfolding and has several components. The first is state-based reform. We were the first, and Vermont followed us about a month later. Right now we see about two dozen states, including Michigan, seriously engaged in figuring out what they can do on this problem.

What’s happening at the federal level?

The second dynamic plays out in Congress this year. There was a program established in 1997, by Congress, called the SCHIP, or the State Children’s Health Insurance Program, which right now provides coverage for about five million lower-income kids across the nation. The program’s ten-year authorization expires on September 30th of this year. If Congress does not reauthorize this program, then coverage for those kids is in jeopardy beginning October 1. So a lot of folks are now pushing Congress to reauthorize it and fully fund it—also to expand it, because there are still another nine million uninsured kids.

How does the presidential race factor into things?

Having a leading Republican contender by the name of Mitt Romney uttering the “U” word—universal—transforms the nature of the campaign conversation. It is now inconceivable for any Democrat to run for president and position themselves to the right of Mitt Romney on health care. We have not seen Democratic presidential candidates use the “U” word since 1992, and they all are now. Also, the other Republican candidates can’t just hand Mitt Romney this issue; they have to get on this game as well, so they are all figuring out how can they talk about doing something big on health care. If we can sustain momentum on all three fronts, then on November 4th, 2008, major health care reform will become an electoral mandate issue for the new president and the next Congress. And then the real fun begins in January ’09.

What do you hope happens?

So many people in the health reform game have their own version of what the world should look like. It borders on theology—you must worship at the shrine of the perpetual single payer, you must bow down before the consumer-driven goddess. Me, I’m an agnostic. Any way that gets us to heaven, I’m on that bus.

Heaven would be universal coverage?


Can it really happen?

If it happens, that’s the sequence, and those are the forces that will come together. If Massachusetts fails . . . if other states, like Michigan and California and Wisconsin, fall on their faces, and no other big things happen . . . if Congress blows SCHIP . . . if the presidential conversation gets distracted from health care . . . then scratch all of the above.

How much of a factor is the failed Clinton health plan of 1993 and 1994?

For health reform veterans, it’s a cautionary parable —a story with a lesson. In ’93–94, the Clintons tried to do two gigantic things at once. They tried to create a durable structure of universal coverage, and they tried to transform the health care delivery system. And they found that attempting to do both was so immense a challenge that the sheer weight of it sunk the whole boat.

What impact has SPH had on your career?

It was the most fantastic educational experience of my life. Everything else paled by comparison. My doctoral experience at Michigan—an On Job/On Campus doctorate—was fantastic. I was a state rep at the time. I was the only elected official who ever did the program. John Tierney taught us health policy and politics, and he exposed us to a set of models that helped me to make conceptual sense of what I had been doing instinctively on the ground for ten years. One was an agenda-setting model by a guy named John Kingdon. I went back to the legislature in 1995 and used that model as my conceptual tool to engineer what we call the second wave of Massachusetts health reform in 1996. Michigan was mind-blowing.

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The Cry for Universal Coverage

Catherine McLaughlin, professor of health management and policy and director of the UM Economic Research Initiative on the Uninsured, worked with John McDonough on his dissertation research at Michigan in the 1990s.

As a member of the Citizens' Health Care Working Group, a 15-member non-partisan commission formed by Congress to gauge public opinion on health-care access, cost, and quality, McLaughlin is seeing the same push for change that McDonough describes.

"In my work on the Citizens' Health Care Working Group, we had meetings in over 30 states, conducted online surveys and polls, and received thousands of e-mails and letters. All told, we had over 30,000 responses from people literally all over the country. The overwhelming majority, over 80 percent, said we need universal coverage and we need it now. This is nationwide.

In March, the Senate Finance Committee held hearings on the working group's recommendations as well as what's happening in Massachusetts and elsewhere. Things are bubbling up. So what John helped push forward in Massachusetts is now happening at the national level. From our perspective, the citizens have spoken, and now the politicians are starting to listen. And that means there's a push for a solution. It's very exciting."