Yesterday Mitt Romney made an impassioned defense of his Massachusetts health reform law and attempted to explain away the obvious similarities between his state reform effort and Obamacare.
About his own plan, he spoke of the moral responsibility of government to help uninsured people get coverage; of the need for an individual mandate to force free-riders to contribute to the system; for subsidies for lower income people; for regulations barring insurers from discriminating.
As Jonathan Cohn notes in his review of the speech, no one but Romney disputes that these provisions match almost exactly the framework used for Obama’s national reform:
Both set up insurance exchanges for people without access to employer insurance. Both require insurers to provide coverage to anybody, at the same price. Both have an individual mandate. Both have subsidies. Both expand Medicaid coverage. Both seek to cover most, if not quite all, residents. Both set requirements for what insurance must cover.
Romney spent a lot of time distinguishing between his reform and Obama’s by appealing to federalism: that a state-based solution to help people get insurance is not the same as the federal government imposing a solution on the whole country. Basically, state-based coercion to improve human welfare is proper and moral, but federal coercion toward the same end is improper, and in fact is some sort of unique imposition on liberty. This is a very nuanced view which I don’t think is going to resonate with many people. There is actually some philosophical coherency to this federalism argument, but not enough to please or convince anyone, left or right. To wit:
The National Review editorialized against Romney’s speech by noting that it’s not the state/federal coercion distinction that bothers them, but the existence of the coercion itself:
[W]hen conservatives argue that Obamacare is a threat to the economy, to the quality of health care, and to the proper balance between government and citizenry, we do not mean that it should be implemented at the state level. We mean that it should not be implemented at all.
I don’t agree with this, but I find it a much more coherent view than Romney’s delicate needle-threading. If you’re an individual rights purist, it shouldn’t much matter whether the mandates come from the state house or the White House; they’re all bad.
The liberal critique is also more coherent. Romney defended his Massachusetts law as both successful centrist policy and an important moral imperative that improved the lives of hundreds of thousands of previously uninsured residents. He said the Mass. reforms worked. Since the federal law relied on the exact same mixture of Romney-approved reforms, why won’t it work also? Romney is either saying that it WILL work, but that he doesn’t care because it’s just too freedom-killing. That upholding his idiosyncratic view of the Commerce Clause or the 10th Amendment is more important than giving the rest of America access to his (in his view) wildly successful reforms. Or else he is saying that it simply won’t work nationally; that his state-based reforms are just incapable of being scaled up for some reason, and that it’s not even worth a try to replicate his Massachusetts miracle. If that is his position, I haven’t heard him make an argument for it.
I said the federalist position had some coherency, but when it comes to health care I really don’t think it holds up. In his presentation Romney hit all the federalist themes: States are the laboratories of democracy, the hotbeds of policy experimentation; that our foundational social contract biases decentralized state-based solutions over federal dictates. Essentially he and other opponents of the Affordable Care Act are arguing that health care/insurance is not a national problem; and so to impose a national solution violates the spirit of the constitution, and perhaps the letter as well.
This idea that health care is not an issue fit for national consideration, and in fact that federal involvement represents some sort of unique death of liberty, is really bizarre to me. There is already broad consensus that the federal government should be deeply involved in the provision of health care to military personnel, all veterans, everyone over 65, poor children, disabled people; am I missing anyone? And of course we think health insurance is so important that we give a giant federal tax subsidy to all people who get their insurance through their employer. Randian free-enterprise state of nature, this ain’t. Even the Republicans’ favorite reform idea, and echoed by Romney yesterday—the ability to buy insurance across state lines—implicitly concedes that the issue transcends a strict state-by-state treatment.
Why can’t Republicans just admit that the federal government already either provides for, regulates, or subsidizes the health insurance of nearly every American? That the ACA doesn’t represent some brand new attempt by Washington to finally get its claws on Americans’ health care. That in fact it’s this system, with the feds already deeply enmeshed in every stage of health care provision and payment, that Republicans fought so hard to preserve, and are fighting now to reinstate. Once we accept the banality of the idea of federal involvement in health care, it seems beyond sensible to say that it might be a good idea to introduce some efficiencies into this crazy state/federal patchwork arrangement featuring fifty different systems, which costs twice the price, and still manages to leave tens of millions uninsured throughout the country.
It is always maddening to recall that this point used to be uncontroversial, even to Republicans. In fact, most of the ACA’s key provisions are formerly Republican ideas; it really makes me wonder what we’d be arguing about if a President McCain had enacted a similar bill. Mitt Romney would probably be his HHS Secretary, overseeing the implementation of the conservative health care triumph which covered nearly every American while promoting individual responsibility, encouraging competition, and preserving the private market.
Instead we are stuck in this dysfunctional partisan tribalist nightmare in which a sensible, smart, very well-informed man has a fatal political problem because of his track record of actually getting things done to improve people’s lives. That sort of governing accomplishment isn’t welcome in today’s Republican Party.
Update: The Onion, of course, got there first.