This week, a grassroots organization in Massachusetts announced plans to launch a ballot initiative to repeal the state’s individual mandate to purchase health insurance. Massachusetts Citizens for Life is primarily concerned about how the growing cost of health care in the state will lead to rationing and denial of care. But it sees repeal of the individual mandate as the key ingredient for an eventual dismantling of the state’s landmark 2006 health-care law.

The law’s defenders point to its role in increasing insurance coverage in the state to record levels (though it is still not universal). But the other side of the balance sheet reveals that an overwhelming number of these newly insured are heavily subsidized through an expanded Medicaid program and a highly regulated “Connector” to coverage for individuals in households earning up to three times the federal poverty level. Meanwhile, other private insurance premiums (particularly for small businesses) continue to rise, in part due to the new law, and Massachusetts remains the “leader” among states in its high overall health-care costs. Unsubsidized Connector coverage for small businesses and other middle-income individuals has found few takers.  

Political promises that the new law would reduce use of overcrowded hospital emergency rooms were overstated. Emergency room visits actually increased over 7 percent from 2006 to 2009. Timely access to primary care remains difficult as a subsidized surge in demand outstrips supply.

Although the higher costs have put some pressure on the state’s own budget, most of them are hidden because they were shifted to federal taxpayers as part of a Medicaid waiver, according to a recent study by the Beacon Hill Institute.

All of the above reflects the calculated political strategy behind the 2006 law: to rapidly increase coverage first and only worry about higher costs years later. Some belated efforts to impose top-down price controls on insurers and providers in the state have mostly floundered thus far.

Apart from touting the initial coverage gains under the new law and recycling anecdotes of how it provided life-saving access to care, the program’s advocates insist that it remains highly popular. Indeed, a Harvard School of Public Health poll earlier this spring reported 63 percent support for the 2006 law (up 10 percent over the last two years). However, support for the individual mandate remains more shaky, with 44 percent opposed (up from 35 percent in a similar2008 poll). And 47 percent of state residents say that the Massachusetts health law should not have been used as a national model (versus 43 percent who like telling the rest of the country what to do).

Will the new effort to roll back the state’s landmark law succeed? Massachusetts voters admittedly have a greater taste for high taxes, more government spending, and overregulated health-care markets than voters in other states (see McGovern 1972; Dukakis 1988; and Kerry 2004). But the proposed ballot initiative would be the people’s first chance to vote on what their politicians and closely linked interest groups delivered five years ago. By targeting the more vulnerable individual mandate, it could unravel the larger ball of yarn.

There is recent precedent for the threat of ballot initiatives to drive political change in Massachusetts. Strong grassroots efforts led to tentative approval of a different one in 2004 to add a right to “comprehensive, affordable, and equitably financed health insurance coverage” to the state constitution, and the possibility that a similar measure to impose a payroll tax on employers in 2006 might succeed added to the political pressure to finally enact the current Massachusetts health law instead.

The actual wording of the proposed ballot initiative first must be certified by state attorney general Martha Coakley before Massachusetts Citizens for Life can begin to gather the almost-60,000 signatures needed to get it on the 2012 ballot. Funny that it should be Martha Coakley — she has some first-hand experience with unexpected grassroots opposition to a new health-care law upending the plans of the state’s political establishment.

— Tom Miller is a coauthor of Why Obamacare Is Wrong for America (HarperCollins 2011).