Partially intended to give his White House dreams wings, ‘Romneycare’ now seen as policy albatross for Republican party
Republican presidential hope Mitt Romney backed universal healthcare coverage as governor of Massachusetts because he thought it would be the triumph that would get him into the White House, according to those who worked with him there.
“He wanted to have a big accomplishment as governor,” said John McDonough, professor at the Harvard school of public health who was closely involved with both the Massachusetts reforms and the Affordable Care Act (ACA) as an adviser to senator Ted Kennedy.
“He chose to run for governor of Massachusetts rather than Utah because he thought it would be a better platform to run for president. He was convinced early on that there was a way to [deliver healthcare coverage for all] that would adhere to Republican principles.”
McDonough thinks there were also personal issues. “There was some influence from his wife’s chronic MS (multiple sclerosis) and his religious background.”
This week the supreme court is expected to deliver its long-awaited judgment on whether Barack Obama’s Affordable Care Act is constitutional.
But whichever way the justices in Washington rule, healthcare will continue to be a central issue in the presidential election campaign. And while Romney has explicitly promised to repeal ‘Obamacare’ on his first day in office, his record in Massachussetts has also come under intense scrutiny, from both conservatives and liberals.
Romney became governor of Massachusetts in 2003. “He said nothing about access at all in his campaign,” said McDonough. But then he gave a speech to the greater Boston chamber of commerce. “He said: ‘I’m working on a universal coverage plan.’ We said: ‘What? Mitt Romney? What happened to him?’”
But Romney realised it was going to be expensive, and the issue went on the back burner until an unexpected threat to health funding in the state blew up.
In 1997, Massachusetts negotiated a Medicaid waiver with the Clinton administration, under which it would run its own programme for the poor called Mass Health.
To ensure that waiver did not damage the safety net hospitals in Boston and Cambridge, Massachusetts senator Ted Kennedy secured special federal assistance worth $100m a year.
By late 2004, this had risen to $384m, and the Bush administration warned it would be axed. Romney was horrified, and so was Kennedy. Instead, they hatched a plan to divert the money into universal healthcare coverage by way of a universal mandate.
Romney signed Massachusetts’ reform into law in 2006. It was only later that it became so controversial.
“It was a very difficult message in 2008,” said McDonough. “Romney was very clearly saying this is a model for the nation, including the individual mandate. He thought it would be a ticket to ride to national fame and glory. He took a position on the mandate that was Republican orthodox in the 80s. All these people were saying this is the way and he had the temerity to do it.
“It was like he was on a ship. He invited Ted Kennedy on. More and more folks came on. Romney wasn’t noticing that as more Democrats were getting on one side, the Republicans were getting off the other.”
It was not until the individual mandate was debated at federal level that it became such a contentious issue. “It is this policy position that was held by the elite in the Republican party which had not ever been tested with the base. Finally it was tested with the base, and [by that time] it was identified with the Democrats and Obama so it was a very bad time.”
The individual mandate in Massachusetts has delivered near-universal coverage – some 98% of people now have health insurance although the figure may be slightly lower if those who are undocumented are taken into the estimation.
There was little resistance, which McDonough attributes to a collective effort to educate the public by insurers, hospitals, politicians and churches – in addition to commercials featuring a Boston Red Sox player with a broken arm. That has not happened with the ACA, he says, where those who agreed it have preferred to distance themselves now.
“In terms of what Massachusetts set out to accomplish, we accomplished it,” says MIT health economist Jonathan Gruber, credited as the architect of the reforms and a key adviser to federal government on the ACA. “We did not set out to accomplish cost control.”
The high costs are now the major issue for the state, but Gruber insists they are nothing to do with the implementation of the reforms. “It drives me crazy to hear that Massachusetts reform is a failure because we have the most expensive care in the nation. It is a stupid and meaningless comment.”
Massachusetts has some of the best and most expensive hospitals in the USA. “They charge an ungodly amount of money for very high quality care,” said Gruber.
‘An unregulated system with big market power’
Partners Healthcare was formed by a merger of Massachusetts General and Brigham and Women’s hospitals. One had 1,000 beds and the other 700.
“There was no economic rationale. The most efficient hospitals are 300 beds,” said former governor Michael Dukakis. “Partners is now getting a huge differential in the way it gets paid. It says to insurers – you want your insured to come to Partners? This is what we will charge you.’ That’s what happens in an unregulated system with big market power.
“My wife wouldn’t be alive today if it weren’t for a doctor at the Massachusetts General. She had 17 years of recurrent depression. ECT saved Kitty’s life. Nobody’s a bigger fan of the folks who provide healthcare in this city than I am. Healthcare in this city will always be more expensive than in cities elsewhere, but there is no excuse for $16,000 per family per year. It is unsustainable.”
Dukakis favours a regulator who will cap insurance premiums. Gruber says it is not so easy. The highest-charging hospitals also have the best results.
“The money isn’t necessarily all waste,” he said.
But US healthcare costs have got to come down from 18% of GDP and rising.
“We have over-treatment at one end and under-treatment at the other. We have never, ever, ever in this country moved even close to half-way,” Gruber said. Hospital costs across the US have almost quadrupled since the 1950s. “Today we waste a huge amount of money on healthcare – the Dartmouth group say it is a third. The other two-thirds is awesome, but we don’t know how to differentiate them.”
Tiered insurance premiums have been introduced now by some companies, which allow patients to go to the most expensive hospitals if they pay extra. Some hospitals are lowering their prices in a bid to get into a more popular tier. “We want a regulatory mechanism to make sure minimum quality is met and then you choose on price,” said Gruber.
There is still plenty to do in Massachusetts, experts say. Nancy Turnbull, senior lecturer in health policy at the Harvard school of public health, worries about the remaining uninsured. A single-payer system, which she would have preferred, would have enrolled everybody resident in the state.
Even now, when the uninsured turn up at the hospital emergency room, there is a chance to sign them up. It could also be done through their tax filings. “I lie awake at night thinking we know who those people are, we know where they live,” she said.
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