Policy Proposals

Taking Massachusetts National: An Incremental Approach to Universal Health Insurance

July 1, 2007
Health Care

The Problem

Far too many Americans lack health insurance; although they are not turned away at emergency rooms, many are not accessing preventive care and are suffering worse health outcomes as a result. These costs ripple through the health-care system as uncompensated care costs, and as a result the insured pay higher taxes and insurance premiums.

The Proposal

This proposal builds on the successes from the universal coverage reform efforts in Massachusetts. Recommendations for national scale-up include creating a state-by-state health insurance market for low-income individuals that features subsidies; allowing those who work, but who still remain below 400 percent of the poverty line, to use a voucher to buy insurance in the low-income market; creating a health insurance pool for middle- and high-income individuals to combine risk; and mandating insurance coverage for all individuals, enforced through the tax code.


The United States is in the midst of another wave of interest in universal health insurance coverage, this time inspired by efforts at the state level. In this article I review what we know about the uninsured and why we should care about covering them. I then discuss the issues that must be addressed to achieve universal coverage, and discuss the Massachusetts reform which tried to navigate between the right and the left on this important issue. I then lay out a plan for universal coverage at the national level which builds on the Massachusetts model. Such a plan would cost $130 billion per year. I also show that such a plan could be readily financed by restructuring the exclusion of employer-sponsored insurance from taxation.