01:00 AM EDT on Thursday, April 6, 2006

BOSTON -- Hillary Clinton and Ira Magaziner were widely criticized in 1993 and '94 for trying to remake the vast, anarchic financing of the American health-care system in secret, behind closed White House doors. With high-minded intentions, the first lady showed she didn't then understand the basic workings of the democratic process.

In Massachusetts in 2006, Salvatore DiMasi and Robert Travaglini -- respectively, the House speaker and the Senate president -- have made Mrs. Clinton's penchant for secrecy seem tame. With the first half of a two-year, $770 million federal Medicaid grant at risk of being forfeited if the state can't come up with a health-care bill in a matter of weeks, the two men shut out all but a few special interests from their many weeks of discussions.

Teaching hospitals have reportedly been in on the plan, as has the Massachusetts Taxpayers' Foundation, which, despite its name, represents big business. But the public doesn't know what's going on, rank-and-file legislators haven't known what's going on, and Governor Romney has been saying he doesn't know what's going on.

Finally, on April 3, Messrs. DiMasi and Travaglini held a press conference to announce the release of a 145-page bill, designed to increase the number of insured in the state, which the two of them now agree on. The House and Senate are expected to act quickly -- possibly voting by the time this article goes to press. Mr. Romney -- his governorship increasingly subordinated to the calculus of his ambition -- is not expected to veto a bill that would, for the time being at least, make him seem effective.

The purpose of the federal "demonstration grant" Massachusetts currently stands to lose is to encourage this state, then others in the future, to increase the number of citizens with health insurance. With a $385 million forfeiture betiding almost immediately, there will be enormous pressure on legislators to vote for the bill, and for Mr. Romney to sign it, without having much of a clue as to what's in it.

For the last four weeks the governor has been saying he could only speculate on what would be in the bill. He may have known more than he was letting on. But if he was kept even partly in the dark about what was being negotiated -- leaving the public, as we know, completely in the dark -- it was a travesty. A miscarriage of the democratic process, and with dangerous ramifications.

With its world-renowned medical and educational institutions, Massachusetts is the ideal think tank for innovation in the economics of medicine. But what we are witnessing -- conniving in secret, then voting under duress -- is the worst possible way to do it, with every likelihood of a fiasco the taxpayer will be stuck with long after this crop of political leaders has departed.

We may have a somewhat better idea of what the DiMasi-Travaglini agreement contains before the legislature votes. But we are not likely to have sufficiently debated its provisions, nor to have thought through its future ramifications. Based on my speaking with legislators and health-care activists, who could, of course, only speculate, here is the scenario I think we ought to worry about:

-- The bill is a sop to the powerful -- it protects big business and rewards big, profitable hospitals with big rate increases.

-- It does not protect small business and small hospitals. It introduces an initially small $295 tax per worker per year on the labor of businesses not providing health insurance.

-- It theoretically increases the number of insured, but has no way of assuring that the expanded coverage is reasonably comprehensive. It becomes, rather, a giveaway to insurance companies, and a bad deal for the newly insured.

-- It doesn't appropriate enough money to provide good insurance. Its mandate for expanded coverage thus becomes what one legislator called "the camel's nose in the tent." When, in a year or two, the new plan is broke, without doing enough for the formerly uninsured, it will need a massive infusion of new cash, including a big increase in the $295-a-year tax on the labor of non-participating businesses.

-- It creates a new bureaucracy with the impossible mandate of effecting top-down, bureaucratic "cost control." This entity doesn't control costs, but rather itself becomes a big cost.

I don't like to speculate and I don't like to be cynical about the work of fellow human beings. But the disgraceful lack of forthrightness by the leaders of the two houses and whomever they may have been confiding in leaves me to fear the very worst.

David A. Mittell Jr. is a member of The Journal's editorial board.