Credit Hog

The Bill Clinton of the 2008 election is not, in fact, likely to share his surname. Hillary will probably run, to be sure. But the part Clinton played in 1992 -- that of an attractive, technocratic, successful governor from a state normally hostile to his kind and boasting substantive accomplishments on issues his party rarely touches -- will be played by a New England conservative named Mitt Romney.

For the last four years, Romney, a Republican, has governed the right wing's geographical bête noire, Massachusetts. More surprisingly, he's made something of a success of it, eschewing tax increases (though loading up on so-called “user fees”) while transforming a $3 billion deficit into a $700 million surplus. That sound you hear is the United States Chamber of Commerce salivating. More impressively, Romney faced down the state's thorny health-care crisis, negotiating with a Democratic legislature to craft one of the most exciting comprehensive reform bills in the nation.

It's the sort of story the press loves: a competent, results-oriented executive corralling his state's rowdy, opposition party -- dominated legislature into solving a seemingly intractable policy problem. Horse-race handicapper extraordinaire Charlie Cook called Romney ”[p]robably the brightest and most talented candidate in the GOP field.” Writing in Time, Joe Klein gushed that he's “the Republican who thinks big on health care,” and called Romney's plan “rather remarkable.”

And that it was. But it wasn't just Romney's plan, and while opinions in Massachusetts differ on exactly who deserves the credit, there is unanimity on two points: first, that Romney will base his presidential campaign on this achievement; and second, that he's exhibited neither the interest nor the ideological flexibility to transport it to the national stage. He may be the Republican who thinks big on health care, and as a presidential candidate, he'll certainly be the Republican who talks big on health care. But those hungrily seeking a serious reformer should look elsewhere.

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Understanding why requires a quick tour through the genesis of the Massachusetts reforms. Media coverage of such plans tends to be personality-based, all the better to tell an easy, compelling story. But such achievements are rarely attributable to the Herculean efforts of a single individual. Credit -- and for that matter, blame -- disperses more widely, and structural factors often matter above all. And so it was with the Massachusetts bill, which grew out of a long-fighting and notably mature health-reform advocacy movement, veto-proof Democratic majorities in the state's House and Senate, a universal health-care ballot initiative that frightened the business community, a federal threat to withhold Medicaid money in the absence of health reform, and a variety of demographic and policy realities unique to Massachusetts.

There is no doubt, of course, that vastly expanding health-care coverage is a tricky proposition. But doing so in Massachusetts is less tricky than doing so virtually anywhere else in the nation. The state is notably wealthy, decidedly liberal, and overwhelmingly insured. Indeed, a mere 11 percent of Massachusetts residents lack health coverage, 7 percent less than the national average. Moreover, the state already had a dedicated pot of money for providing health care to those who failed the wallet biopsy.

Generally, hospitals are forced to care for the uninsured, but they are not compensated for the effort. So they raise prices for insured patients -- a sort of invisible tax. But the Massachusetts hospital lobby is particularly powerful, and it had long before pushed for a state-run uncompensated care fund, financed through general revenue and taxes on hospitals and businesses. That tax meant the state started with $540 million to play with -- $540 million that wouldn't require the raising of new revenues.

Meanwhile, the federal government, unhappy with the free ride Massachusetts was offering its uninsured population, threatened to pull its Medicaid waiver, worth more than $700 million over 2007 and 2008. If the state wanted to keep the money, it had to reform its system. As if that was pressure enough, on Romney's right, the Health Care for All lobby, along with the Greater Boston Interfaith Organization, had laid the groundwork for a ballot initiative creating an expansive universal health-insurance program, to be financed primarily through new payroll and cigarette taxes.

The lobby was no joke. Health reform, after all, has a long and storied history in the state. In 1988, then-governor Michael Dukakis signed into law a universal system based on an employer mandate. The mandate, which would have forced employers to either offer care or pay the state to do so, was never implemented and got quietly repealed a year later. But much of the plan did take effect, and coverage was significantly expanded. In 1996, the forces of reform won another round, widening the MassHealth insurance program to include some 350,000 low-income residents of the state. The arc of health-care reform was toward greater progressivity, and it excited a powerful advocacy community determined to reach the holy land of universal care.

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It would almost be fair to say that the advocates had an ally in the governor's mansion. Romney, to his credit, was open to health-care reform. Hungry for higher o¡Þce but lacking in substantive legislative achievements, Romney began studying the issue with an eye toward making it his own in the spring of 2003. In May 2004, Ron Preston, then Romney's health and human services secretary, offered a plan that achieved near-universality through savvy use of the uncompensated-care fund and a hefty tax on employers unwilling to offer benefits. Romney didn't quite throw Preston out of his office, but nor did his final product look much like Preston's bill. What Romney offered, in July 2005, was an individual mandate with little concern for affordability and less for comprehensiveness. It would have likely ushered in a host of plans with massive deductibles and serious cost sharing; coverage, to be sure, but sparse coverage that shifted risk toward individuals.

Romney's relatively stingy plan had little chance of becoming law. But it was an admission that, if the ballot initiative were to be headed off and the federal waiver preserved, something would have to be done. And on some level, Romney held surprisingly few cards, given the state's veto-proof House and Senate Democratic majorities. The Massachusetts Senate, led by Robert Travaglini, was willing to accept less comprehensive measures, but the state's House, under Speaker Salvatore DiMasi, held firm to an expanded version on Romney's bill, this one coupling Romney's individual mandate with an employer mandate, free rider provisions (a method of penalizing large businesses that don't offer insurance), heavier subsidies, and an as-of-yet undefined "affordability clause" that demanded insurance be affordable if individuals were to be forced to purchase it.

And in the end, that's the bill that emerged. The employer mandate, requiring no more than a $295 per-worker tax on employers who refuse to offer health care, wasn't particularly substantial, but it exists, and could easily be raised in the future -- a future that might come soon, given that Romney's successor is expected to be a Democrat. The program was folded into an appropriations bill so Romney could line-item veto the most liberal portions, a savvy bit of kabuki theatre that will allow Romney to distance himself from the final plan's employer mandate and increased progressivity on the campaign trail.

Still, Romney received -- and deserved -- plaudits for his flexibility and willingness to cut a deal. But with the federal government's threat to revoke the Medicaid waiver and the health lobby's ballot initiative pressing the issue, Romney had no choice. And while the end result was relatively progressive, the Legislature's Democratic majority ensured that it couldn't really emerge any other way. What Romney did was insist there be no revenue increases to fund the plan. "He just wasn't going to look at any new taxes," said John McDonaugh, president of Health Care for All, "even the silly cigarette tax we put on the table ¡­ He's a serious no-new-taxes kinda guy." One of the architects of the bill, who was insistent that Romney deserves credit for its passage, nevertheless admitted, "I think [a national universal-care program] isn't really where he's at. He's been so clear with his no-new-taxes view, and to do it at the national level would require significant taxes and he just won't support that. His heart may be in the right place, but he won't fight the political fight of raising taxes for it."

And if he's unwilling to engage that battle, he's useless. Any similar plan on the national stage would require new taxes, or at least new revenue. Massachusetts boasted both an uncommonly slight uninsured population and a pre-existing pot o' cash to pay for their care. The national situation isn't nearly so rosy. Unwilling to raise taxes and unconstrained by a Democratic Congress, Romney may run on health care, but he's unlikely to fight for it. And the punditocracy, so excited by the Massachusetts plan, should demand some sign to the contrary before voting him "Most Likely to Reform Health Care" in the class of 2008.