Health care reform became law, and within four years, 98 percent of the population was covered by insurance. Only 0.2 percent of all children remained uncovered. Racial and ethnic disparities in coverage largely disappeared. Public support for reform hovered at 65 percent, and there was no movement to repeal the law.

Is this the future of U.S. health care? Right now, it is the current status of Massachusetts' health care reform law, the basis for the nation's Affordable Care Act (ACA), passed by Congress in 2010. What does the state's experience foretell of the future of the national plan? A panel of experts convened to discuss this topic on April 16 at the annual meeting of the Association of Health Care Journalists in Philadelphia.

The federal plan, like Massachusetts reform, rests on a balky, Byzantine health care system with spiralling costs driven by special interests, such as the insurance industry and drug makers. Both plans mandate coverage, create a health insurance "exchange" marketplace, expand Medicaid, set minimum coverage standards for insurance and provide subsidies for low-income Medicaid-ineligible people to purchase it--if making below 133 percent of the federal poverty level (currently, $10,400 for a single person) under the federal program and if making below 300 percent of federal poverty under the Massachusetts program.

The issue of the system's costs is going to make or break reform in Massachusetts, said Rob Restuccia, executive director of Community Catalyst, a non-profit advocacy organization based in that state. Same goes for U.S. health reform.

"Before the ACA is fully implemented in 2014, Massachusetts will have to address issue of cost," Restuccia said. "Whether we are successful will be a bellwether for the nation."

It is projected that per capita health expenditures in Massachusetts will double in the next eight years, he said. Monthly insurance premiums for employees have as much as doubled for some Massachusetts employers, sometimes even on plans offering minimal coverage. Health care will become unaffordable if nothing is done. (Some state lawmakers, however, are working on legislation aimed at bringing costs under control. They could mimic the federal plan, which includes tools for managing costs, such as incentives for hospitals to prevent re-admissions and hospital-borne infections such as Staph.)

For the moment, though, there is little evidence that Massachusetts employers have dropped insurance benefits for employees or that public insurance is crowding out employer-sponsored coverage, Restuccia said.

Overall, most Massachusetts employers believe health reform has been good for the state and most physicians are on board as well, saying that reform has not adversely affected quality of care, according to data collected by the Blue Cross Blue Shield Foundation of Massachusetts, said journalist and panel organizer Irene Wielawski.

A backlash against the state's health care reform never materialized, and the program currently has support from Sen. Scott Brown, Gov. Deval Patrick and former Gov. Mitt Romney, a likely presidential candidate in 2012.

Despite the successes, the Massachusetts plan intentionally avoids covering some and unintentionally missed some others. It excludes legal immigrants and fails to reach people who can't afford health insurance even after the potential subsidies. Young men in their 20s are one of the least insured demographic groups in the state; they tend to feel invincible and some have found ways to circumvent the mandate.

An example came from WFCR public radio reporter Karen Brown, based in Amherst, Mass., who told a story of a woman she interviewed who worked as a maid making $1,500 a month. Her employer offered insurance that would have cost her $1,600 a month. She appealed the state mandate to purchase the policy and won, avoiding a tax penalty.

Another unaddressed issue related to the Massachusetts plan is the difficulty in finding a primary care doctor, even for those who are insured--one in five adults in the state report facing this problem, Restuccia said. Emergency room admissions have increased, many of which could have been prevented if patients had received primary care earlier. A similar trend is taking place nation-wide, but the ACA aims to expand the number of primary care workers and increase prevention services.

The Massachusetts plan also has one huge difference compared with the federal one: the state already had a robust health care system and infrastructure, Restuccia said. Some 94 percent of state residents had insurance even before reform; nation-wide, that figure is about 83 percent.

For instance, much of the burden to insure people under the federal program will have to be borne by Medicaid, said Robert I. Field, a professor in the law school and the school of public health at Drexel University. That's not a big deal in states already set up to provide coverage to those ranging up to the 133 percent of poverty level. In states such as Alabama, where Medicaid only covers down near 20 percent of the federal poverty level, the federal program will require a huge ramp-up.

In any case, "thick skin" is advisable for all in the coming years as U.S. health care reform implementation (or an effort to dissemble it) progresses. Brown, who has covered health care in Massachusetts for several years, used that phrase in a sheet of tips and lessons that she distributed to conference attendees. Many non-journalists alike could appreciate her wisdom. Among her observations: "It's common to be accused of anti-reform bias when reporting on consumer complaints--and conversely, to be accused of acting as a government mouthpiece when reporting on people happy with the way things have changed."

Image credit: New York City Health and Hospitals Corp.