Over the past several days, a flurry of stories has raised red flags about the prospects for state-based health care mandates. On Saturday, the AP reported that soaring costs are buffeting the pioneering insurance mandate program in Massachusetts. Just days earlier, the New York Times described a Massachusetts primary care system now swamped with new enrollees seeking treatment. And complicating matters further, the deepening recession is hitting state budgets hard, producing a financial crisis almost certain to halt the expansion of state-based universal health care coverage.
First, a little background. Under a law signed in 2006 by then Governor Mitt Romney, Massachusetts residents beginning this year are required to obtain health insurance either through work or the private marketplace. While coverage for lower income residents is subsidized (or exempted) by the state, those not acquiring insurance face fines and tax penalties. Businesses with 10 employees or more must also provide health care coverage or similarly face penalties from the state. By December 2007, Massachusetts announced that 300,000 people had enrolled in new insurance programs. Still, between 100,000 and 300,000 (according to the federal government) remain without coverage.
Despite the early success in reducing the pool of the uninsured, Massachusetts is already experiencing spiraling costs for the program. The $1 billion experiment as initially designed was supposed to be paid for largely from the state's existing fund for emergency medical care for the uninsured. With the program's costs now expected to hit $1.4 billion, Governor Deval Patrick signed a $400 million expansion for 2009. To fund it, the state is looking to pass a new dollar-a-pack cigarette tax designed to generate over $150 million in revenue annually. Meanwhile, penalties for non-compliance are also being raised, up to $912 for individuals and $1,824 for families on top of the $219 personal tax exemption.
The good news coming out of the Commonwealth - over 300,000 more residents now possessing medical insurance - is also creating growing challenges for Massachusetts' primary care physicians now overwhelmed by the newly covered. As the New York Times detailed, the program's very success is producing waiting lists and long delays for patients:

Here in western Massachusetts, Dr. Atkinson's bustling 3,000-patient practice, which was closed to new patients for several years, has taken on 50 newcomers since she hired a part-time nurse practitioner in November. About a third were newly insured, Dr. Atkinson said. Just north of here in Athol, the doctors at North Quabbin Family Physicians are now seeing four to six new patients a day, up from one or two a year ago...
...The share who accept new patients has dropped, to barely half in the case of internists, and the average wait by a new patient for an appointment with an internist rose to 52 days in 2007 from 33 days in 2006. In westernmost Berkshire County, newly insured patients are being referred 25 miles away, said Charles E. Joffe-Halpern, director of an agency that enrolls the uninsured.

As the Times details, skewed market forces and an overemphasis on specialized treatment has left the primary care system in Massachusetts - and nationwide - simply unable to provide routine, preventive care when Americans' access is dramatically increased. Dr. Patricia A. Sereno, state president of the American Academy of Family Physicians, put it:

"It's a recipe for disaster. Its great that people have access to health care, but now we've got to find a way to give them access to preventive services. The point of this legislation was not to get people episodic care."

For other states contemplating the Massachusetts model, the American economic slowdown is quickly rendering such debates moot. Facing a massive $16 billion deficit, California has been forced to backburner Governor Schwarzenegger's ambitious $14.7 billion universal health care proposal. Across America, the news is grim for the country's governors. As the Washington Post recently reported:

State budgets have been hit hard by a worsening national economy, including rising costs for energy and health care. In addition, fallout from the subprime mortgage crisis -- declining home sales, deflated property values and mounting foreclosures -- has caused a slide in states' anticipated tax receipts. Revenue from property taxes, sales taxes and real estate transfer taxes is affected.
At least half of the nation's states are facing budget shortfalls, some of them severe, and policymakers in most of the states affected are proposing and passing often-painful measures to trim costs and close the gaps. Spending on schools is being slashed, after-school programs are being curtailed and teachers are being notified of potential layoffs. Health-care assistance is being cut for the elderly, the disabled and the poor. Some government offices, such as motor vehicle department locations, will start closing on weekends, and some state workers are receiving pink slips.

The impact of these budget shortfalls on the future of state-based health care coverage is clear. As Ezra Klein argued in his prescient Washington Monthly piece last summer ("Over Stated"), state "laboratories of democracy" cannot achieve universal health care:

Over the years, states have tried programs of many different ideological and economic persuasions. All of them failed, and not because the programs were insufficiently inventive, but because states are structurally incapable of sustaining them.

Analyzing the histories of health care initiatives in Hawaii, Washington and Tennessee, Klein showed the impact that economic downturns have had in undermining the viability of even initially successful programs. At the time he wrote his piece, Klein predicted that Massachusetts "may be the exception that proves the rule," given its high median family income and comparatively low numbers of uninsured residents.
This triple whammy of an inadequate primary care system, rising costs and recession suggests that the solution to the American health care crisis must come from the nation's capital and not the state capitals. (Governor Deval Patrick's lukewarm response to Hillary Clinton's call for a national health insurance mandate may have less to do with being an Obama supporter and more to do with his experience in Massachusetts.) The emergency of 47 million uninsured Americans needs to be treated not in Boston, Sacramento or Santa Fe, but in Washington DC.