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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.


Grassroots anger: Opposition to health care reform helped spark the tea party movement.(Chet Susslin)

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 presumptive GOP presidential nominee, he may finally 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 able to train his fire on other targets.

Calling attention to what’s 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.


To the extent that Romney continues to assail the law, he’ll focus, as he has for months, on the federal government’s new role as regulator of the health insurance industry. Romney’s chief defense of the Massachusetts law 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.

“It was always a liberal pipe dream that a 2,700-page, multitrillion-dollar federal takeover could actually address the very serious problems we face with health care,” Romney said on the law’s second anniversary. “Sadly, the law itself is fast becoming the national nightmare that I and other critics have
always predicted.”

“Trying to do a major overhaul of everything all at once is not productive and [is] problematic.”—Tevi Troy, Romney health care adviser

But, of course, his Massachusetts plan and the federal law 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 also 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 do more than seek to eliminate what he describes as an unpopular, bureaucratic program; he would effectively be denying insurance to 30 million people, as well as 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. To the extent that he has offered his vision for health care reform 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 insurance companies can spend on overhead to the menu of benefits that 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?


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 health 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 May 12, 2012 edition of National Journal Magazine.

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