Part 4 in a developing series of in-depth analysis by Dr. Jeff Fuller (See part 1 and part 2 and part 3)
Preface for RedState: I’m interested in the opinions of the community here regarding this perspective on RomneyCare and the issue of insurance mandates. In this I am not trying to argue that I personally am a big fan of a health care individual mandate. At best, I view the individual mandate as the lesser of two evils in our current health care system (a way to try to bring an element of personal responsibility at the state level to combat the federal long-standing mandate included in EMTALA/COBRA laws which require all people in the US be seen/triaged/treated upon presentation to ERs irrespective of their insurance or immigration status)
Firstly, as an addendum to my last post (Part 3 about Romney opposing ObamaCare from Day one), Romney has upped the ante on his rejection of ObamaCare and his willingness to fight for it’s repeal. In a brief National Review Online Op-ed on March 22nd entitled “If I Were President: ObamaCare, One Year in” he brought up a new angle that I hadn’t considered:
If I were president, on Day One I would issue an executive order paving the way for Obamacare waivers to all 50 states. The executive order would direct the Secretary of Health and Human Services and all relevant federal officials to return the maximum possible authority to the states to innovate and design health-care solutions that work best for them.
As I have stated time and again, a one-size-fits-all national plan that raises taxes is simply not the answer. Under our federalist system, the states are “laboratories of democracy.” They should be free to experiment. By the way, what works in one state may not be the answer for another. Of course, the ultimate goal is to repeal Obamacare and replace it with free-market reforms that promote competition and lower health-care costs. But since an outright repeal would take time, an executive order is the first step in returning power to the states.
Powerful, pragmatic leadership, with both experience and foresight. That’s what our country needs in the White House, and that’s what Mitt Romney has in spades!
OK, now onto the questions of RomneyCare and Mandates. Admittedly, this will be the stickiest subject for Romney and may be a stumbling block of gaining the support of some conservatives. The individual mandate is at the crux of both ObamaCare and RomneyCare, really, the sine qua non of the respective plans.
Mitt recently defended the individual mandate. This has been his consistent position since 2004-5 when the law was being crafted. In fact, Romney was often questioned about the plan during the last GOP primary in 2007-8 and he provided solid answers about how an individual mandate could help solve the problem of “free riders” . . . those that could afford health insurance, but choose not to because current federal law MANDATES that emergency rooms assess/triage/treat all patients who present, irrespective of their insurance status or citizenship (EMTALA & COBRA laws: “It requires hospitals and ambulance services to provide care to anyone needing emergency healthcare treatment regardless of citizenship, legal status or ability to pay. There are no reimbursement provisions. As a result of the act, patients needing emergency treatment can be discharged only under their own informed consent or when their condition requires transfer to a hospital better equipped to administer the treatment.”) Take 81 seconds and hear Mitt discuss the conservative side of the mandate issue during a 2008 GOP debate:
http://www.youtube.com/watch?v=gn42BFs0_b4 (trouble embedding this YouTube here at RedState for some reason)
I like how Romney summed this up in writing in the following WSJ article in 2006:
“Some of my libertarian friends balk at what looks like an individual mandate. But remember, someone has to pay for the health care that must, by law, be provided: Either the individual pays or the taxpayers pay. A free ride on government is not libertarian.”
“. . . the individual mandate was originally a Republican idea. “It was invented by Mark Pauly to give to George Bush Sr. back in the day, as a competition to the employer mandate focus of the Democrats at the time.”Pauly, a conservative health economist at the University of Pennsylvania’s Wharton School, says it wasn’t just his idea. Back in the late 1980s — when Democrats were pushing not just a requirement for employers to provide insurance, but also the possibility of a government-sponsored single-payer system — “a group of economists and health policy people, market-oriented, sat down and said, ‘Let’s see if we can come up with a health reform proposal that would preserve a role for markets but would also achieve universal coverage.’ ”
The idea of the individual mandate was about the only logical way to get there, Pauly says. That’s because even with the most generous subsidies or enticements, “there would always be some Evel Knievels of health insurance, who would decline coverage even if the subsidies were very generous, and even if they could afford it, quote unquote, so if you really wanted to close the gap, that’s the step you’d have to take.”
One reason the individual mandate appealed to conservatives is because it called for individual responsibility to address what economists call the “free-rider effect.” That’s the fact that if a person is in an accident or comes down with a dread disease, that person is going to get medical care, and someone is going to pay for it.
“We called this responsible national health insurance,” says Pauly. “There was a kind of an ethical and moral support for the notion that people shouldn’t be allowed to free-ride on the charity of fellow citizens.”
The Heritage Foundation, a prominent conservative think tank, has been a long term supporter of the idea of an individual mandate . . . even testifying before Congress in 2003:
. . . it is also reasonable to expect residents of the society who can do so to contribute an appropriate amount to their own health care. This translates into a requirement on individuals to enroll themselves and their dependents in at least a basic health plan – one that at the minimum should protect the rest of society from large and unexpected medical costs incurred by the family. . . .
The obligations on individuals does not have to be a “hard” mandate, in the sense that failure to obtain coverage would be illegal. It could be a “soft” mandate, meaning that failure to obtain coverage could result in the loss of tax benefits and other government entitlements.
After RomneyCare was passed, the Heritage Foundation provided Mitt with plenty of support and even “cover” for the individual mandate (scroll down to one of the last sections entitled “Personal Responsibility” at that link.) However, they have back-tracked fairly strikingly on the issue since 2007. (to be “fair and balanced” the CATO Institute . . . a prominent libertarian think tank . . . has always been opposed to an individual mandate and RomneyCare.)
But not all conservatives have left Mitt alone holding the bag on the mandate issue recently. Newt Gingrich has repeatedly documented his support of health insurance mandates:
June 2008 Associated Press article: “Gingrich suggests insurance mandate for those who can afford.” According to a June 11, 2008 Associated Press article (accessed from the Nexis database), which ran under the headline, “Gingrich suggests insurance mandate for those who can afford,” Gingrich reportedly “outlined his strategy to combat rising health care costs a plan of attack that includes insurance mandates for people who earn more than $75,000 a year” at a visit to a Nebraska health system. The article went on to report that “Gingrich called it ‘fundamentally immoral’ for a person who can afford insurance to save money by going without, then show up at an emergency room and demand free care. He said those who can afford insurance and choose not to buy it should be required to post bonds to pay for care they may someday need… Gingrich said everyone should have insurance, but not provided by the federal government.”
Also, at the same source, it gives us two gems from two of Newt’s recent books: in his 2005 book “Winning the Future” — “we should make it clear that a 21st Century Intelligent System requires everyone to participate in the insurance system” — and in his 2008 book “Real Change” –“we should insist that everyone above a certain level buy coverage.”
The BIG problem for Newt if he ever gets called to task on this issue is that NEWT SEEMS TO BE SUGGESTING AN INDIVIDUAL MANDATE AT THE FEDERAL LEVEL, WHILE MITT HAS NEVER SUGGESTED OR RECOMMENDED SUCH A THING, but has consistently reiterated that this plan/mandate work for Massachusetts, but probably wouldn’t work in many other states.
I guess I shouldn’t be too rough on Newt though, as he provides a pretty stellar defense of Romney and RomneyCare when speaking to David Brody of the Christian Broadcasting Network:
http://www.cbn.com/cbnnews/Video-Embeds/2010/November/Gingrich-6/?WT.mc_id=EmbedNewsPlayer
Rewinding back to 2005-6, the individual mandate in RomneyCare was better than the Democrat’s competing legislation that called for huge employer mandates, something that would have put nearly all the burden of health care onto businesses. Doing such would have been anathema to conservatism AND would have driven many employers and their jobs out of Massachusetts. A recent Boston Globe Editorial summed up much of this process, providing precious perspective as to Romney’s role in keeping the legislation as conservative as possible.
“conservatives might be more favorably disposed [toward RomneyCare] if they understood the part Romney played in warding off various schemes feared by business. . . . the approach many Democrats favored: a payroll tax of 5 to 7 percent on businesses that did not offer health coverage. That idea, the subject of a planned ballot question, became the preferred approach of then-House speaker Sal DiMasi. Businesses worried, and with good reason, about the costs such a plan would impose.
DiMasi, however, remained adamant about putting much of the responsibility on business, something both Romney and then-Senate president Robert Travaglini opposed. At one point, DiMasi talked of forcing firms to pay $800 to $1,000 per uncovered employee.
The compromise that finally broke the long stalemate was based on an individual mandate, but called for companies without coverage to pay $295 per worker per year. That was essentially the Romney plan, but with enough of a business contribution to let DiMasi save face. In a move that angered DiMasi, Romney signed the bill, but vetoed the business levy. The Legislature overrode his veto, reimposing the fee.
All in all, then, the role Romney played was of a governor sensitive to business concerns and worried about the state’s business climate. Now, conservatives have come to view that individual mandate as an intolerable imposition on personal liberty, rather than an insistence on personal responsibility. In no small part that’s because such a mandate also plays a central role in Obama’s health care plan. But if they weren’t hyperventilating about the national law, they might come to recognize that the role Romney played on the state level was skillful, creative, and business-friendly.
What speaks volumes to me is that Mitt Romney was able to achieve a more conservative bill in the most liberal state in the union than Obama managed to foist upon a center-right nation.
What remains to be seen is exactly how Romney will address this hot-button issue on the campaign trail. I think he 
should and will stick by his guns that the idea of an individual mandate has some conservative appeal. Will he be able to re-package this idea for conservative audiences, attempting to re-sell the idea back to it’s original source? I think it will be difficult for some voters to get by. Will it be a “deal breaker?” Maybe for a small minority. However, I think that the vast majority of GOP voters will fall into one of the three categories.
- They will accept (or at least understand) the merits of an individual mandate as far as RomneyCare is concerned.
- They will continue to oppose a federal mandate as unconstitutional, but allow flexibility at a state level for things like a mandate.
- They will realize Mitt’s the best candidate to win a general election against Obama and will “forgive” him on thsi issue of the individual mandate.
RomneyCare may be a “speed bump” on Mitt’s path to the nomination, but it will not be the death knell. The fact that Mitt blows away all the other GOP competition in MA and NH (where they know him AND RomneyCare the best) primary polling give me great confidence that Romney and RomneyCare will “wear well” on the nationwide electorate as the campaign progresses.
-Jeff Fuller, M.D.
*Stay Tuned: Future installments will address topics of 1) Federalism, 2) Whether or not RomneyCare is a “success”, 3) a head to head comparison of RomneyCare vs ObamaCare, and 4) an analysis of where other GOP candidates have been on RomneyCare and Health Care in general. Previous installment titles: Part 1: “Mitt Romney vs. Health Care: ‘The Problem’ (Or is it?)“, Part 2 “Mitt Romney vs. Health Care: ‘Why RomneyCare Makes Mitt the BEST Nominee to Face Obama‘”, and Part 3 “Mitt Romney vs. Health Care: ‘The Bottom Line . . . Mitt Romney Stands Strongly Against ObamaCare; Will Work Towards and Sign a Repeal of ObamaCare as Our Next President’”
It’s often revealing to turn conventional wisdom on its head and see what’s really hidden underneath. You’ve all heard it, I’m sure, that RomneyCare is Mitt’s doom, an albatross around his neck, his biggest weakness as a potential candidate. In 
Moe Lane
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