The complicated story of ‘Romneycare’

By guest blogger, Tom Packer

Mitt Romney is in all but name the Republican nominee for President of the United States. There is, therefore, a decent chance he will be the next President and it is certain he will have a major impact on the US healthcare debate. Romney is committed to repealing ‘Obamacare’ and to sweeping, if vague, free market reforms of the US healthcare system.

However it’s not clear that Romney’s healthcare agenda will pass congress. Thus the history of Romney and healthcare policy is worth looking at for guidelines to his future behaviour. It’s a history that at first glance seems to contradict his manifesto but at second glance is much more complicated.

Romney as Governor of Massachusetts was central to the passage of the Massachusetts Health Care Insurance Reform law, in 2006. The powers of the Massachusetts Governor are roughly equivalent at state level to the President’s nationally – that is, he can veto (subject to a 2/3 override) legislation, but he can not write or impose legislation. Moreover Massachusetts is easily among the least Republican and conservative states in the US, with Democrats holding a massive majority in both houses of the state legislature. Thus Romney was an outlier in the political culture of Massachusetts.

‘Romneycare’, which remains Massachusetts state law, seems to commentators on both the left and the right obviously similar to Obamacare.  More or less all the ‘core’ features of Obamacare are in it including a mandated benefits package, guaranteed issue and ‘exchanges’ where individuals and companies can  purchase health insurance. Possibly most controversially of all it introduced an ‘individual mandate’ compelling individuals to buy health insurance.

This was despite the fact that Romney had an adversarial relationship with the state legislature, and that Romney’s political advisors were, for the most part, lukewarm to his push.


One significant factor was that Medicaid (the federal government programme) was providing over $300 million dollars a year to keep Massachusetts hospitals solvent. Unless a law was passed allowing this funding to be redirected to individuals it would all be cut off.

However Romney has not stressed this point, but has defended the law on the merits. This is particularly striking given how many positions Romney has shifted – to an extent that he has (not entirely fairly) become notorious for politically driven ‘flip flops’.

When seeking to differentiate Romneycare from Obamacare, Romney has focused on details (such as some of the taxes introduced) or constitutional issues (arguing the mandate is not constitutional when done by federal rather than state governments). Few pundits have found these arguments compelling. The argument from the details has been seen as minor and the constitutional argument has stretched credibility from the technocratic Romney.

Ironically though there are three central ways in which the apparent similarity between Romney’s policy history and Obama’s is misleading. Massachusetts health policy is much less the result of Romney’s intent than the history outlined above might suggest.

Firstly, in many ways the core of Obamacare was already part of Massachusetts state law. In particular in 1996 the Non-Group Health Insurance Reform Act had been passed. This forced insurers to offer everyone insurance (‘guaranteed issue’) and offer it at fairly similar rates (‘community rating’), and also included a large number of mandated benefits. As I have already explained these elements form the core of Obamacare which necessitate other elements such as the mandate. In a sense the core of Obamacare had been passed in 1996 – to a certain degree Romneycare was a rationalising measure. After all the Obama administration has argued those elements of Obamacare are inextricably linked to a mandate.

Secondly, large parts of the bill were only passed over Romney’s veto, particularly the mandates forcing employers to purchase health insurance.

Thirdly, the implementation of the law took it in a very different direction from Romney’s vision of it as explained in this excellent article by Avik Roy. In particular Romney sought to reduce the mandated benefits from the 1996 law and to make more use of co-payments. Because of disagreement between Romney and the state legislature, however various state boards were given most of the responsibility for defining these crucial and central aspects of the law.

Romney’s successor was Deval Patrick a left of centre Democrat even by Massachusetts standards. He appointed people to these boards with a very different vision from Romney. The result was that co-payments were eliminated for those earning less than 150% of the federal poverty level and that guaranteed benefits were actually expanded-and included areas like substance abuse programmes.

Thus on the one hand Romneycare in many respects does look very much like a state version of Obamacare. On the other hand its usual nomenclature is crucially misleading. In large measure the core of Obamacare was already state law in Massachusetts. At the same time other very important aspects were not the result of Romney policies but of decisions taken by his much more left of centre successors.

It is rather remarkable how Romney has not sought to make more of these factors. One possible explanation is that it would undermine his claims to be a successful executive. That is because the story of Massachusetts healthcare reform is in many respects not so much of Romney ‘betraying’ conservative principles as his attempts to uphold them being frustrated by superior political forces and of Romney’s failures to predict this.

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