Romney's Unlikely And Persuasive Defense Of The 'Individual Mandate'

Jan 27, 2012
Originally published on January 27, 2012 4:19 pm

For a candidate who keeps vowing to repeal the 2010 federal Affordable Care Act, former Massachusetts Gov. Mitt Romney sure can make a convincing argument on its behalf.

At least that's how it appeared to a lot of people after last night's Republican Presidential debate in Jacksonville, Fla.

During a more than 10-minute back-and-forth on health care largely between Romney and former Pennsylvania Sen. Rick Santorum, Romney ended up delivering a lengthy justification for his state's decision to pass a 2006 law that included requiring nearly every resident to either have health insurance or pay a tax penalty.

"If you don't want to buy insurance, then you have to help pay for the cost of the state picking up your bill, because under federal law if someone doesn't have insurance, then we have to care for them in the hospitals, give them free care," said Romney. "So we said, no more, no more free riders. We are insisting on personal responsibility. Either get the insurance or help pay for your care."

"Does everybody in Massachusetts have a requirement to buy health care?" asked Santorum?

"Everyone has a requirement to either buy it or pay the state for the cost of providing them free care," Romney shot back. "Because the idea of people getting something for free when they could afford to care for themselves is something that we decided in our state was not a good idea."

Santorum's conclusion was that "in Massachusetts, everybody is mandated, as a condition of breathing ... to buy health insurance, and if you don't ... you have to pay a fine."

But backers of the requirement saw Romney's explanation in a somewhat different light.

Said John McDonough, a professor at the Harvard School of Public Health, "Romney has given in this entire presidential campaign last evening what I believe is the most effective and persuasive rationale and defense of the individual mandate."

Of course, that may not be a good thing for Romney as he fights to win over Republicans who dislike the 2010 law in general, and the insurance requirement in particular. Santorum said the Massachusetts law passed under Romney's stewardship in 2006 is too close to the federal law for Republicans to make health care an issue this fall.

"It does not provide the contrast we need with Barack Obama if we're going to take on that most important issue. We cannot give the issue of health care away in this election," he said.

And while Romney insisted that the Massachusetts law and the federal law differ in significant ways, McDonough, who was intimately involved in the development and passage of both the Massachusetts and federal health laws, insists that's not really the case.

"The similarities go far far beyond the mandate," he said. For example, "the essential architecture of the insurance reforms in the Affordable Care Act are taken wholly from the Massachusetts health reform law."

On the other hand, Santorum may have overspoken when he claimed that the Massachusetts law isn't working very well.

Just this week the policy journal Health Affairs published a study looking at the Massachusetts program's first five years in operation.

"We find the state is continuing to do quite well in terms of maintaining high levels of health insurance coverage and improvements in access to care," said lead author Sharon Long of the University of Minnesota and the Urban Institute. "Including for the first time we're seeing reductions in emergency department use, and also some improvements in health status. So really, some very positive changes that came with health reform."

Positive for Massachusetts residents, perhaps. Positive for Mitt Romney's chances to win the Republican nomination? That still remains to be seen.

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Most of the coverage of last night's Republican debate has focused on the clashes between Newt Gingrich and Mitt Romney over relatively personal issues. Those include Romney's wealth and whether or not Gingrich ever lobbied.

As NPR's Julie Rovner reports, this 19th debate also featured one of the liveliest exchanges yet over the very public issue of health care.

JULIE ROVNER, BYLINE: The health issue was raised, not by a member of the media, but by a voter, Jacksonville resident Lynn Frazier. She described herself as unemployed for the first time in 10 years.

LYNN FRASIER: And unable to afford health care benefits. What type of hope can you promise me and others in my position?

ROVNER: None of the candidates pointed out that Ms. Frazier would likely get help under the Affordable Care Act, the federal law that passed in 2010. Depending on her income, she'll either be eligible for Medicaid or a subsidy to help her buy insurance starting in two years.

One thing all the candidates agree on is they want to see that law repealed. But Frazier's question sparked quite a debate between former Senator Rick Santorum and former Massachusetts Governor Mitt Romney.

Santorum said the Massachusetts law passed under Romney's stewardship in 2006 is too close to the federal law for Republicans to make health care an issue this fall.

RICK SANTORUM: And it does not provide the contrast we need with Barack Obama if we're going to take on that most important issue. We cannot give the issue of health care away in this election.

ROVNER: Romney insisted that's not the case, that the Massachusetts law and the federal law differ in significant ways. But then he launched into an eloquent justification for the requirement at the heart of both measures, the so-called individual insurance mandate.

MITT ROMNEY: Under federal law, if someone doesn't have insurance, then we have to care for them in the hospitals, give them free care. So we said, no more. No more free riders. We're insisting on personal responsibility.

ROVNER: In fact, says John McDonough, a professor at the Harvard School of Public Health, Romney did something President Obama himself failed to do in his State of the Union earlier this week.

JOHN MCDONOUGH: Romney has given, in this entire presidential campaign, last evening, what I believe is the most effective and persuasive rationale and defense of the individual mandate.

ROVNER: The bad news for Romney, however, at least in a GOP primary, is that it's not just the individual insurance requirement that the Massachusetts and federal health laws have in common, says McDonough, who was intimately involved in the drafting of both measures.

MCDONOUGH: And the similarities go far, far beyond the mandate. The essential architecture of the insurance reforms in the Affordable Care Act are taken wholly from the Massachusetts health reform laws.

ROVNER: On the other hand, Santorum may have over-spoken when he claimed that the Massachusetts law isn't working very well. Sharon Long is a professor at the University of Minnesota. Just this week, the policy journal Health Affairs published her study looking at the Massachusetts program's first five years in operation. She says, overall, the state's doing very well in terms of getting nearly all of its citizens insured.

SHARON LONG: Including this year - for the first time, we're seeing reductions in emergency department use and also some improvements in health status. So, really, some very positive changes that came with health reform.

ROVNER: Positive for Massachusetts' residents, perhaps. Positive for Mitt Romney's chances to win the Republican nomination? That still remains to be seen.

Julie Rovner, NPR News. Transcript provided by NPR, Copyright NPR.