As the Massachusetts Senate race between Democrat Martha Coakley and Republican Scott Brown came to its dramatic conclusion on Tuesday, the press repeatedly echoed the phrase "referendum on health care." There was a good reason for this: Brown vocally positioned himself as the "41st vote" needed to defeat passage of the Senate health care bill.For Democrats, it's heartbreaking that Massachusetts may decide the fate of federal health care reform, given that Brown's predecessor, the late Senator Edward Kennedy, was a lifelong champion of the issue. On one level, however, the Bay State's revolt is fitting: several years ago, it became a laboratory for health care reform with the passage of its own legislation. Massachusetts' current plan covers 97% of the populace, a higher percentage than other state in the nation, and problems with growing insurance premiums and high overall spending on health care are a big part of what pushed angry voters to the polls.

Bringing Everyone to the Table

But some have pointed out that Massachusetts is a particularly difficult state in which to control costs. It has faced the same difficulties as the federal government in getting stakeholders -- including doctors, hospitals, insurers and consumer groups -- onto the reform bandwagon. As Kevin Sack pointed out in a New York Times article in March, Massachusetts has "more doctors per capita than any state, Boston is home to some of the country's most expensive academic medical centers, and a new state law requires comprehensive benefits like prescription drug and mental health coverage."

Since the state's health care legislation passed, cost cutting measures have not kept up with the rise in spending. Combined with the recession, Massachusetts's health care crisis is squeezing the general public. No wonder voters elected Brown, the kind of candidate that the state's deep blue political machine would normally have eaten for breakfast.

Tough Lessons

So what can we learn from Massachusetts? The state is now playing tough with many of the parties involved in health care, and if the Democrats want to snatch reform from the jaws of defeat, they will have to do the same. This will mean revisiting the cost cutting measures discussed in 2009, many of which were discarded because of special interest groups. Some of the areas to address include the way doctors and health care institutions are reimbursed, the services they provide, the need for cost-effective and evidence-based approaches to treatment, programs to incentivize good health (as opposed to just treating disease) and the limits on who can qualify for coverage. Keeping Massachusetts in mind, Congress will need to work quickly if it hopes to outpace rising costs. Eventually, legislators may look back at passing the health care reform act as merely the first step in a long and difficult process.

Of course, Brown's shocking victory means that passage of the legislation is even more imperiled. However, I disagree with Brown, who has said that it's best to "go back to the drawing board." This would signal a clear defeat for Democrats and -- more importantly -- for America's citizens, who now have the potential to receive the best medical care in the world. Worse yet, Brown's modest proposal would leave the health care problem to evolve -- or devolve -- on its own. The health care system would likely continue on its current path, leading to more uninsured and underinsured citizens, more bankruptcies caused by medical bills, and an economic state in which a staggering and ever-increasing portion of America's GNP continues to be dedicated to medical care that doesn't rate as highly as that of many industrialized nations.

Desperate Straits

In my office, more and more of the care that I provide is paid for by patients themselves before high deductibles are met. Additionally, more of my patients who used to have other private insurances are now covered by Husky, Connecticut's state-run Medicaid program. Without reform, it's likely that more businesses will end up purchasing expensive health insurance plans for their employees, which often force employees to pay for much of their care anyway. At the same time, fewer employers will offer health insurance altogether, and fewer patients will find affordable private plans, thus perpetuating the health care problem and forcing an ever-increasing expansion of Medicaid and Medicare. The number of people enrolled in Medicaid rose 5.4% in 2009 as a result of the recession, and this trend is likely to continue in 2010, according to a 50-state survey by the Kaiser Family Foundation's Commission on Medicaid and the Uninsured.

While the Massachusetts upset seems to be a backlash against President Obama's health care plan, we still have an historic opportunity to make real changes to our health care system. It's going to be a tough sell, and the Democrats may need to temper their words, scale back their ambitions, and perhaps compromise with a plan that insures fewer Americans. It may boil down to whether we are willing to take a chance like Massachusetts did and get our citizens covered first, then continue to do the hard work of figuring out cost containment. If the second part of this equation is not addressed quickly and firmly, the whole thing could blow up in our faces.

In Massachusetts, the battle still rages. For the rest of the nation, it remains to be seen if health care reform of any sort passes, so that we can at least get in the game.

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