Even though Mitt Romney has had a string of primary wins, support for his presidential bid still is tepid among Republican voters nervous about Romneycare. He could calm them if he were to more fully explain the difference between his vision for reform and the law that ultimately was enacted in Massachusetts.
Gov. Romney gets big applause when he pledges to repeal Obamacare, but he faces silence when he tries to defend Romneycare. He insists, for example, that his individual mandate only impacted the 8 percent of residents who were uninsured (the mandate covers everyone), that he didn't cut Medicare (states have no authority over Medicare), and that he would issue a waiver to the states to implement Obamacare their way (a president can't undo an Act of Congress with a waiver).
The voters are not reassured. Gov. Romney can get off the defensive and change the subject by explaining that the Massachusetts law which was passed by the overwhelmingly Democratic legislature diverged significantly from his vision for reform, and then describe what his reform plan would be as president.
During the presidential debate in Jacksonville, Florida, in late January, Romney took a small step in this direction when he acknowledged that his successor, Gov. Deval Patrick, has taken a much more liberal track in implementing Romneycare. "If I were governor," Romney said, "it would work a heck of a lot better." Indeed, when it passed the law, the legislature was counting on a Democrat governor to succeed Romney to put the real regulatory thumb screws in place.
The Massachusetts law is different in important ways from the plan that Romney pushed as governor. Few voters know, for example, that Romney strongly opposed the employer mandate and wanted an escape from the individual mandate -- allowing people to instead be able to post a bond if they were uninsured and had big medical bills. When Romney signed the law, he believed it contained the escape hatch, but legislators removed it before final passage.
Romney vetoed eight provisions of the Massachusetts bill, and every one of his vetoes was overridden by the legislature. Should Romney have known this was likely? Yes. Should he have known exactly what he was signing? Absolutely. But voters may be more forgiving if he tells them he wanted to give citizens and employers a way out.
Why did he push Romneycare? The state was at risk of losing $385 million in federal Medicaid money, and the Bush administration insisted Massachusetts make changes to get more residents covered and keep the money flowing.
Romney also wanted to find a way to make it easier for small businesses and individuals to get insurance that would be portable from job to job. To get around federal tax law restrictions and to make health insurance portable, he adopted the Heritage Foundation's proposal to create exchanges that would allow individuals to have portable insurance and pay premiums with pre-tax dollars.
TODAY ROMNEY SAYS, "The market can work to solve our health care needs." The policy recommendations on his campaign website back up his perspective on patient-centered reform. But primary voters aren't. He needs to get off the defensive and take charge of this issue.
Here's a three-step plan:
Step 1: Focus on Repeal of Obamacare.
Gov. Romney needs to get his message straight, or he will be hammered in the general election over false promises. He calls for repeal of Obamacare while saying he would immediately issue an executive order to give flexibility to the states to implement the law their way. That sets the stage to massively confuse the political agenda: He would be sending the states off to begin to implement Obamacare while Congress works in Washington to repeal it.
Further, the Congressional Research Service issued a report that said Obamacare's major provisions are Acts of Congress, and they simply cannot be changed through an executive order.
His focus should be on repeal. Waivers to the states from Obamacare are not a solution and, in fact, might well detract from the ultimate goal of repealing the law and replacing it with a genuine free market alternative. If Gov. Romney is serious about repealing Obamacare, he will have to devote all of his energies to doing that as soon as possible.
The House of Representatives passed a repeal bill a few weeks after Republicans took control last year. In the Senate, many parts of Obamacare could be repealed through reconciliation with only 51 votes should Republicans take control there, allowing them to enact legislation repealing the spending provisions that are the biggest threat to the economy and to the federal deficit.
He also could calm voters by emphasizing that a federal mandate to purchase health insurance is unconstitutional and detail more reasons why Obamacare's government-centric approach is wrong.
Step 2: Explain what really happened with passage of Romneycare.
Gov. Romney's support for states' rights is important, saying the law worked for Massachusetts but that other states need their own solutions in our diverse and complex country. But conservatives would feel better knowing what he initially proposed in the Bay State. For example:
• Mandate escape. Few voters know that Romney wanted an escape from the individual mandate. Voters may be more forgiving if he were to tell them he wanted to give citizens a way out and that he strongly opposed the employer mandate.
• Real insurance. Romney wanted people to be able to purchase real health insurance that would have covered catastrophic events. Instead, the legislature insisted on including all of the 50-plus health insurance mandates already on the books. The legislature allowed the high-deductible plans only for some young people aged 18-26.
After the Massachusetts law was passed by the legislature, Romney continued to try to reshape it with his line-item veto. For example:
• Employer mandate: Vetoed. The bill called for a mandate on employers with 11 or more workers to provide health coverage or pay an annual fee of $295 per worker. Overridden.
• Covering certain immigrants: Vetoed. The bill included a provision that would allow some non-citizens to qualify for coverage under the new health plan. Overridden.
• New bureaucracy: Vetoed. The bill created a powerful new bureaucracy, called the Public Health Council. Overridden.
• Limiting improvements to Medicaid: Vetoed. The bill restricted changes to Medicaid to make the program more efficient. Overridden.
Gov. Romney must clarify that in working with a Republican Congress on a new health reform agenda, he would start with a very different vision than Romneycare and work much harder to make sure the consumer-friendly structure is what becomes law.
Step 3: Emphasize his vision for market-based health reform, with a much clearer description of what a President Romney's plan would look like.
He needs to talk about what he would do so he can stop having to defend Romneycare. A handful of specifics would do, many of which are included on his campaign website:
1) Help states set up functional pools so people with pre-existing conditions are protected.
2) Provide new subsidies for the uninsured to purchase the coverage of their choice.
3) Encourage the states to set up marketplaces for people to buy insurance and allow policies to be purchased across state lines.
4) Boost insurance rules to guarantee that if people have coverage, they can keep it and their premiums won't skyrocket if they get sick, etc.
5) Move toward a system of tax credits and deductions to allow individuals to buy and own portable health insurance.
And regarding the "free-rider" problem Romney says that the Massachusetts law was designed to stop: This can be addressed without a mandate and in a way that is likely to be much more effective. For example, if people don't buy coverage with the credit, then the credit could be used to automatically enroll them in a private plan that would cover their major medical bills. Properly structured incentives would be more effective than a mandate in expanding coverage.
The health reform plan Gov. Romney pushed in Massachusetts was different in key respects from the model that became Obamacare but few people know the truth about Romneycare.
Unless Gov. Romney takes steps to clarify and remedy his position, he will continue to have trouble convincing Republican voters he is serious about repeal and will have an even harder time mapping a clear plan on health reform should he be elected president.