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HEALTH CARE

Past Imperfect

Ever since Mitt Romney disavowed his role in the federal health care overhaul, he has struggled to articulate his views on reform. There’s no doubt, however, where President Obama stands, whether America likes it or not.

The most gruesome, avert-your-eyes aspect of Mitt Romney’s tortuous effort to distance himself from his signature achievement as Massachusetts governor may be over. As the GOP presidential nominee, he should be able to spend less time worrying about shoring up his right flank by condemning the Affordable Care Act—and, by implication, the similar state law passed on his watch—and more time training his fire on other targets.

Calling attention to what has been derisively termed “Obamacare” was never a winning play for Romney. His scathing criticism produced an almost unresolvable tension between his current persona and the governor he was, a feedback loop that implicated Romney as much as the president. (Indeed, in August, Romney’s campaign seemed to cautiously embrace the Massachusetts law, to the consternation of conservatives.)

 

To the extent that Romney continues to assail the federal law, he’ll focus, as he has for months, on the government’s new role as regulator of the health insurance industry. His chief defense of the Massachusetts statute has been that it was a state-specific solution to a problem, not something intended for a national scale, and it’s true that he has never favored increased federal control over the insurance industry at any time in his career. Romney has vowed to let states opt out of the law’s requirements as soon as he becomes president—and to push for legislation to repeal it outright.

But, of course, his Massachusetts plan and the federal one share many important similarities. They both aim to help individuals buy insurance through state-based “exchanges.” And they both require people to have health insurance or pay a fine. Romney’s law expanded Medicaid and offered subsidies to help low-income people buy insurance, just like its federal counterpart. Obama’s reelection campaign loves to suggest that Massachusetts furnished the entire model for the federal law.

More important, the Obama team contends that were Romney to become president and advocate repeal, he would not just be seeking to eliminate what he describes as an unpopular, bureaucratic program; he would effectively be denying insurance to 30 million people, rolling back guarantees that those with preexisting medical conditions can get affordable coverage, and taking money back from seniors struggling to pay for their prescription drugs through Medicare.

 

So far, Romney’s health care agenda isn’t an affirmative one. He seeks to destroy more than to create. In his broad-brush vision circa 2012, the proposals seem to be decidedly warmed-over GOP pitches to loosen controls on insurers and unfetter the free market. On that score, at least, the gulf between Romney and Obama is wide. The health care law that Obama signed puts the federal government squarely in control of the private health insurance industry, regulating everything from how much money insurers can spend on overhead to the menu of benefits they must include in certain plans.

That translates, philosophically, to a wider debate about access to coverage. Should it be the government’s role to pool risk to bring down the cost of health insurance and ensure that benefits are available to those most in need? Or should the market be left to its own devices to produce cost-saving efficiencies and tailored insurance plans?

FREEING INSURERS

Romney’s position on health care and the law he helped enact in 2006 has always been more nuanced than his detractors on both the right and the left would have you believe. John McDonough, a professor at Harvard University’s School of Public Health, says that even though the resemblance between Title I of the federal law—which establishes insurance exchanges—and the Massachusetts law is “striking and unmistakable,” it’s not entirely fair to call the state law “Romneycare.”

As a Republican governor working with a Democratic Legislature, Romney didn’t get everything he wanted, notes McDonough, who helped write the federal legislation. Romney sought but failed to get looser restrictions on the policies that consumers would be required to buy under the law.

 

“He really preferred a much thinner form of coverage for people ... that would have only required very thin catastrophic coverage as the form of the mandate,” McDonough said.

Romney now prefers an even more bare-bones option on the federal level. In a health policy plan he sketched on the second anniversary of the Affordable Care Act’s signing, he rolled out a laundry list of the long-standing GOP-favored fixes to the insurance market.

He wants to let states pick and choose among the rules that the federal law puts on insurance plans, such as limiting how much they can spend on overhead or requiring reviews of premiums that increase 10 percent or more. Romney proposes capping medical-malpractice awards and enabling individuals and small businesses to join together to buy insurance coverage. He also wants to allow insurers to sell policies across state lines, a change that advocates say will increase competition and lower prices.

This article appears in the August 25, 2012 edition of National Journal Magazine.

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