Romney’s original health reform goals differed from final plan

Politico

Saturday, Nov. 26, 2011 | 2 a.m.

Mitt Romney has spent a lot of time defending himself over the Massachusetts health care law. But there’s another way to judge his health care record: Look at what he wanted to do.

And what he wanted to do was a bit different than what happened after he signed the law as governor.

Romney wanted a lighter mandate, with a way to get out of it if people were willing to pay something upfront to cover them in catastrophic events. He didn’t want to cover as many benefits. And he didn’t want to expand Medicaid at all.

His vision was never going to fly in the liberal state — so he signed a much different version into law, often described as a framework for what was to come. But his original plan shows that his own ideas were more market-driven, with fewer required benefits for health plans and no mandate for small businesses to offer health insurance.

If Romney had stayed on as governor, or if he had been succeeded by another Republican rather than Democrat Deval Patrick, “the law would have looked very, very different,” said Amy Lischko, who was commissioner of the Division of Health Care Finance and Policy when the law was passed.

•••

The story of Romney’s original vision for health care could easily get lost in the presidential race. That’s especially true now that the Supreme Court is set to review President Barack Obama’s health reform legislation, which draws key elements from the Massachusetts law.

And ultimately, it may not make a big difference to voters. Romney can’t avoid being judged on the version he signed into law — just as Obama, who didn’t want an individual mandate when he was a presidential candidate, signed it into law anyway and is now stuck with it.

“The fact is, he (Romney) signed it,” said Jonathan Gruber, a Massachusetts economist and a key architect of the law.

But whenever people hear about that law — and especially about Romney’s individual mandate — they’ll get a clearer picture if they hear the rest of the story.

The law that is in place in Massachusetts today is one part Romney and one part Democratic Legislature. Yes, the individual mandate was his idea — but his version was different. And there were legislative overrides of eight Romney vetoes, and regulations put in place by the Massachusetts Connector Board, a bipartisan board of stakeholders and governmental appointees charged with making key decisions about health care in the state.

Romney has been repeatedly forced to defend the central (and perhaps most controversial) piece of the law, the individual mandate, as a “plan that was right for Massachusetts.”

“We dealt with a challenge that we had, a lot of people that were expecting government to pay their way. And we said, you know what? If people have the capacity to care for themselves and pay their own way, they should,” Romney said at the Republican presidential candidate debate in Las Vegas.

But what Romney doesn’t mention is that his original plan for an individual mandate included an “opt-out,” which would have allowed people who didn’t want to buy insurance avoid the mandate penalty if they purchased a kind of bond that would cover them in catastrophic events.

“Romney’s mandate was certainly a lighter mandate,” said Lischko. “If people wanted to pay out of pocket for doctors visits, we wanted to let them — but make sure everyone had some type of catastrophic coverage. The individual mandate as it stands today was determined through regulations after the law was passed.”

Lischko, who is now an associate professor at Tufts Medical School, noted that when the law was signed in April 2006, Romney had announced he would not seek a second term and the law he signed “was fairly broad,” leaving much of the detail to be filled in by the next administration.

In fact, both liberals and Romney agree on this point.

“We knew the next governor was likely going to be a Democrat,” said John McDonough, who at the time was the executive director of Health Care For All, a consumer advocate group. “So Democrats in the state decided to put off key decisions around implementation until a new administration came in.”

And in his book “No Apologies,” Romney concedes: “Even the best written legislation is subject to rulemaking and interpretation by political appointees and it can be adjusted by subsequent administrations.”

The Patrick administration does not dispute the idea that its interpretation of the law may vary from what Romney had in mind for the state.

“Gov. Patrick essentially inherited the law and has been an excellent steward for its implementation,” said Glen Shor, executive director of the Massachusetts health insurance exchange, called the Connector.

However, Shor says the Connector Board’s decisions on the mandate, affordability, and minimum essential coverage are made without partisan squabbling. The board includes political appointees, business and insurance representatives, consumer advocates and health policy experts.

The varying interests charged with making the policy decisions “have repeatedly made them unanimously, and the result has been a very mainstream interpretation of the law,” Shor said.

Another key difference is that the final bill included a “play-or-pay” provision for small businesses, something Romney opposed.

The House added the employer mandate provision — fines for small businesses that did not offer health insurance — and Romney subsequently vetoed the measure. The Legislature overrode his veto, and as a presidential candidate, Romney has been able to defend himself on this point.

Additionally, Romney notes in “No Apologies” that expensive insurance mandates like in vitro fertilization and dental care in “low-cost” insurance plans were also added to the final package despite his vetoes.

“The system we were working in already was government-heavy. Romney wasn’t working with a clean slate. Massachusetts already had many insurance mandates and guaranteed issue, so from that standpoint it was hard for him to really create a fully market-driven system,” Lischko said.

McDonough said that every stakeholder in the state, including Romney, ended up agreeing on the pillars of the law.

“The key components from Romney’s original proposal to what was in the final law are all there: insurance market reforms, the individual mandate, subsidies, the exchange,” McDonough said. “But yes, the Legislature filled in the blanks, and it’s markedly different than what he had in mind.”

•••

Republican strategist Ron Bonjean said Romney has been right to not try and get too into the weeds on the details of the health law on the campaign.

“At this point, he’s simply forced to defend the law, and having him reopen and re-litigate parts of the plan is probably a bridge too far,” Bonjean said. “He needs to be focusing on jobs and the economy, and he’s playing it smart to stay away from it as much as he can.”

Bonjean said Romney may be able to point out some of his original goals if he becomes the Republican nominee and has the opportunity to debate President Barack Obama on health care, but it is “too early to tell.”

Lischko said she doesn’t think Romney is running away from the law, and points out that he hasn’t shied away from defending it on the national stage.

“I don’t think any of us expected this to be as controversial as it is,” she said. “You maybe lose the public when talking about the finer points of the legislation, but Mitt is correct when he says Massachusetts is really a lot different that the rest of the country and what works there probably won’t work in Texas or California.”