Devil is in the details of Mass. health care law

"I was moderately outraged," Smith said while grilling burgers and assembling lobster rolls. He called health insurance "something for your own good that you're being required to do."

Persuading the young and healthy to join the health plan is key to its success. That's why the state is spending $1.3 million to advertise on Red Sox cable broadcasts. "Their audience is ours," said the spokesman for the state program, Richard R. Powers. "Most of the people in the state who haven't gotten insurance are young, and most of those are men."

So far, only a few thousand people a month have signed up, but the deadline is still four months away, and even then the penalty for noncompliance is weak. Those who can't show proof of insurance by the end of 2007 lose their state tax exemption when they file their income taxes in 2008, or about $219.

The penalty increases in January 2008. For every month in 2008 that they don't have insurance, residents will have to pay a penalty of up to half the cost of the lowest-cost plan. That could be as much as $150 a month, or $1,800 a year, due at tax time in 2009.

The definition of personal responsibility may be expanding. As the Boston Globe's liberal editorial page said of the penalties, "That's tough, but it's necessary to change the behavior of people who are used to going without insurance, either because they are healthy or are accustomed to relying on the Uncompensated Care Pool to pay for their care."

‘A stiff requirement’
Smith sounds like he'll go ahead and sign up.

"I'm required to shell out an additional 6 grand a year now," he said, guessing at what it might cost him. "I mean — that's a stiff requirement when you're only making 30 grand a year or under, you know?"

Out front at Arnold's, owner Nickerson shows off the new mini-golf course he installed at a cost of nearly $1 million. ("Renting golf balls," he said with a mixture of disgust and rapture.) While he is glad to offer health insurance and to help pay for it, he said, he doesn't like the government’s forcing him to do it.

David Friedman / MSNBC.com David Smith works the grill at Arnold's. He may sign up for health insurance but says, "I was moderately outraged."

"I think that's basically how liberal government works — liberals in the government work," he said. "They force-feed you things that they feel are good for you, like it or not. And that's the way it is. ... There's so many regulations on every level now, to try to run a business, it's very, very difficult. Having said that, I'd like to see everyone with health insurance."

Even employers who already offer insurance will face higher costs under the new law, because more employees will be pressed to sign up for the company health plan. Nickerson said just a little more cost could tip over some small businesses.

"The way I figure my cost is not the cost of the actual item, but what it costs me to keep Arnold's running year to year," Nickerson said. "And it's having less and less to do with the cost of the fish or the cost of the seafood, as it does the cost of insurance and lawyers and taxes. So that's why the continued push to place more burden on the small-business man is going to eliminate more small businesses, and we are the core of the economy down here."

Hoping for failure?
The Massachusetts plan is a political experiment, too.

Will the political left accept a reform that leaves insurance companies in the central role, instead of a Canadian-style system run by the government?

Will the political right accept a reform that coerces employees and employers into buying a particular product?

What effect will its success or failure have on reform efforts in other states and in Congress?

And what impact will it have on the 2008 presidential campaign, particularly for Mitt Romney, the former Massachusetts governor who proposed much of the program?

So far, the coalition that birthed the new law is holding: Consumer groups, employer groups and state officials all said that the plan is fair and has a chance to succeed, at least if the growth in health care costs can be stemmed.

"It's a truly noble experiment," said Michael J. Widmer, the president of the Massachusetts Taxpayer Foundation, a research group run by employers and associations. "I'm hardly naive, but I have to say the complexity of this as it has unfolded has awed me. I think where we are today is remarkable, given the complexity of all this."

As for Romney, the taxpayer group has been critical of his claims that he turned around the state's economy — "there's been no turnaround," Widmer said. But on health care, "he and his team were very skillful in how they handled months and months of wrangling. This is the signal achievement of his administration."

Consumer groups also support the new law, but would like to see the demands on employers greatly increased. They wanted a Canadian-style program but saw that it had no chance here.

"We love single-payer, but it's not politically viable in this state," said Lindsey Tucker, health care reform coordinator for the consumer group Health Care for All. "There are too many interests, the government, the providers. That wasn't an option. This idea of shared responsibility — it's amazing how well it has worked. It's very exciting."

That doesn't mean the law is without its detractors.

Mass. Connector Authority Jon Kingsdale

"I would like to say this," said Jon Kingsdale, a former insurance company executive who is executive director of the state's new health care agency. "Frankly, there are a lot of people outside of Massachusetts who, I think for ideological reasons, want this to fail."

"On the far left, there are people who are single-payer enthusiasts. On the far right, there are market enthusiasts. ... Nobody in America wants to be told what to do," Kingsdale said.

"But for the vast majority of people who are already buying health insurance, 90 to 95 percent, they're going to benefit from having that last 5 or 10 percent to buy in."

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