Obamaneycare: Trotskyite takeover or big company bail out?

By Mike Miliard
11:20 AM
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It's almost too perfect.

Of all the GOP candidates President Barack Obama could possibly face in the 2012 election, he's been matched against Mitt Romney.

As presidential opponents tend to be, Romney and Obama are on opposite sides of nearly every policy issue – not least, if only ostensibly, healthcare.

Except for one uncomfortable fact. Obamacare – the "Crown Jewel of Socialism" (in Michele Bachmann's famous turn of phrase), which has been decried by many on the right as nothing short of socioeconomic Armageddon – is based almost exactly on the healthcare law Romney spearheaded as governor of Massachusetts in 2006.

It's an ironic and vexing state of affairs. A fact that Romney has tried to deflect, deny and otherwise shy away from thus far on the campaign trail.

For that precise reason, of course, it's a fact Obama has been all to happy to highlight – never missing a chance to tweak Romney with reminders of his former self. In April, for instance, on the sixth anniversary of the Bay State's healthcare reform law, the Obama camp released an ad spotlighting the many things the two laws have in common.

So how similar are Obamacare and Romneycare?

Short answer: Very.

Same, only slightly different
The two laws share the same philosophy of near-universal coverage and the same basic "three-legged stool" structure: 1) disallowing discrimination by payers; 2) mandating that people purchase coverage; and 3) subsidizing that coverage for those who can't afford it.

And not only that. Both laws were designed and drawn up by some of the same economists and health policy experts, such as Jonathan Gruber, a professor of economics at MIT (pictured at top left).

"Basically, they're the same [bleeping] bill," Gruber told the New York Daily News.

In an interview with Healthcare IT News this week, Gruber used no such salty language, alas, but his message was the same.

"Obamacare is based on Romneycare," he says. "Myself and a number of Massachusetts experts were brought down to Washington to help them develop it, based on what we'd done in Massachusetts."

[Q&A: A county-level candidate discusses talking healthcare on the campaign trail.]

One big difference?

"Obamacare is more ambitious in one important way: Romneycare did not try at all to tackle healthcare cost control, whereas Obamacare does," Gruber says. "So you can think of it as a more ambitious version of Romneycare.”

Sure, there are many other variations, as one would expect, between a law crafted for a commonwealth of 6.5 million people and another designed for a nation of 312 million.

And they aren't always different in the ways one might expect. When it comes to the much-maligned "individual mandate," for instance, while Romneycare penalizes Massachusetts residents who don't buy insurance a not insubstantial $1,200, the penalty under the Affordable Care Act is $695, or 2.5 percent of income.

Both laws require citizens to buy insurance, and both require employers to provide it. In Massachusetts the penalty for businesses with 11 employees or more who don't make a "fair and reasonable contribution" to their health coverage is about $300 per worker. With Obamacare, the businesses required to comply get bigger (only those with 50 or more people on their payroll), but so do the fines: $2,000 penalty per employee.

"In the Massachusetts law we have a very small penalty for employers who don't offer health insurance," Gruber explained. "With the federal law, it's much larger. I would say that's a very big difference."

Other small differences are more or less cosmetic. While both plans allow kids to stay on their parents' insurance until age 26, for example, Romney's law specifies that they maintain coverage for two years after they stop being claimed as dependents or until they turn 26, whichever happens first.

[Feature: Washington gubernatorial candidates at center of national health debate.]

But one more big place the laws are at odds has to do with the subsidies they offer to help people purchase insurance. The Bay State subsidizes folks who earn up to 300 percent of the poverty level; the ACA helps out anyone under 400 percent of the poverty level – but gives them less of a subsidy.

"In Massachusetts, our subsidies to low-income families are much more generous than those in the federal law," Gruber adds. "The federal law makes low-income families pay a lot more of their healthcare costs than does the Massachusetts plan."

So yes, there are differences – but in Gruber’s words, "the basic structure's the same."

Which is why it’s so galling – if entirely unsurprising – to see Romney (pictured at right) either avoiding or disavowing his signature achievement as governor when he's on the hustings.

Disingenuous Romney
When Romney does deign to speak about the Massachusetts law, he is mealy-mouthed, essentially saying healthcare laws should be up to the states, or that what was good for Massachusetts is not necessarily good for the rest of the country.

"That's disingenuous," says Gruber, a Democrat. "First of all, there's no reason why it wouldn't be right for other states. He never says why."

[Political Malpractice: How politics distort Americans' perception of health reform.]

Second, Gruber says, the only reasons Massachusetts could enact its law in the first place was with the help of federal contributions. "So if Romney's willing to say, 'I'll pony up the money for other states that want to do this,' that's one thing. But he's not saying that,” Gruber adds. “You can't do it without the same help from the federal government that we got. So he's being very disingenuous in that position."

Beyond fiscal issues, however, Romney is also being ideologically insincere.

When Romney left office in 2007, he and his aides took with them hard drives from 17 state-owned computers, having also scrubbed emails from his office PC.

But earlier this month, the Wall Street Journal uncovered a trove of correspondence that showed just how strongly he believed in his health reform law – especially the individual mandate.

Indeed, his aides even toyed with some ideas that were too extreme for Democrats, such as naming and shaming employers that didn't offer coverage.

"I know the ems hate this, but we can also [throw] back in the Gov's original notion of having some sort of 'public disclosure' of employers who promote a culture of uninsurance," wrote Romney adviser Cindy Gillespie on Feb. 13, 2006.

Romney made no secret of his affection for the individual mandate. He had no reason to, since it's essentially a conservative idea. As he wrote in a July 2009 USA Today op-ed, recently dug up by BuzzFeed:

Our experience also demonstrates that getting every citizen insured doesn't have to break the bank. First, we established incentives for those who were uninsured to buy insurance. Using tax penalties, as we did, or tax credits, as others have proposed, encourages "free riders" to take responsibility for themselves rather than pass their medical costs on to others. This doesn't cost the government a single dollar. Second, we helped pay for our new program by ending an old one — something government should do more often. The federal government sends an estimated $42 billion to hospitals that care for the poor: Use those funds instead to help the poor buy private insurance, as we did.

"He was a firm believer in the individual mandate," Gruber says. "He believed in it very strongly on moral grounds, and basically felt there were people in Massachusetts who could afford health insurance and weren't buying it, therefore free-riding on the rest of us.

[Related: 3 ACA aspects states should keep no matter how SCOTUS rules.]

"My contribution to the debate was to bring the numbers to bear and say, not only is that a moral argument, there's actually a financial argument that it's a cost-efficient way to cover the uninsured," Gruber adds. "Those arguments together got him very excited about the mandate and he was a huge proponent."

Republicans falling for pieces of Obamacare
Simply put: Obamacare is a conservative plan with the very intention of reforming the payment system to save the federal government – and its taxpayers – billions if not trillions of dollars, and simultaneously bolster patient care.

"The credit here should go to Barack Obama for adopting a fundamentally Republican plan [rather than] universal coverage. So thumbs up to him, and thumbs down to Romney and the Republican Party for essentially running away from their idea," Gruber says. "I mean, at the [Massachusetts] bill signing, on the podium was a guy from the Heritage Foundation, a conservative think tank, praising the conservative principles behind this bill. I mean, that was six years ago! This wasn't a hundred years ago, it was six years ago. It's pure, craven politics that they're now running away from this."

But now that Romney is the settled-upon GOP nominee, with the Supreme Court set to hand down its ruling on the Affordable Care Act any day now, an interesting thing has been happening.

In some ways, it seems that the cognitive dissonance of trying to pretend that a fundamentally conservative law is actually a Trotskyite takeover is starting to catch up with some Republicans.

"As Washington faces the very real prospect of the Supreme Court striking down all or part of Health Care Reform, Republicans are deciding there are many parts of the bill they want to keep after all," Josh Marshall wrote on his Talking Points Memo blog on June 6, in a post titled Learning to Love 'Obamacare'.

Indeed, it seems that allowing parents to keep their adult kids on their policies, and prohibiting denial of coverage for preexisting conditions, are even popular among GOP constituents. Which shouldn't be too surprising since Romney once espoused them.

[Political Malpractice: The very partisan strategy around men's reproductive health.]

“It would be hard to write a 2,700-page bill and not have something in there that you like,” said Rep. Phil Roe (pictured at top left), MD (R-TN).

Despite maintaining that “the whole bill needs to be replaced,” Rep. Tom Price (R-GA) said “there are some things that have been instituted that a lot of folks have begun to rely upon and plan – make their family plans – based upon. Twenty-six-year-olds being on their parents’ insurance is one of them.” (Price pictured at right)

Even Romney's own campaign staffers are finding things to like in Obamacare.

Michael Leavitt, the former governor of Utah and HHS Secretary under George W. Bush, has been named to head Romney's transition team. No particular surprise there. Like Romney, Leavitt is a Mormon and, like Romney, a devout conservative.

But some on the right are blanching at the fact that Leavitt is a big fan of one of the key provisions of the Affordable Care Act.

"Leavitt has said some relatively positive things about certain elements of Obama’s health reform law, suggesting earlier this year that 'Obamacare' empowers the HHS secretary 'to do certain things that are clearly aimed at trying to move us in the right direction,'" Jonathan Martin and Alexander Burns wrote on Politico earlier this month.

Specifically, Leavitt likes health insurance exchanges (HIX). “We believe that the exchanges are the solution to the small business insurance market,” Leavitt's chief aide, Rich McKeown, told Politico. The site pointed out, however, that HIX aren't just a "matter of principle for Leavitt – they’re also a cash cow." What’s more, Politico reported, the size of his health consultancy, Leavitt Partners, "doubled in the year after the bill was signed as they won contracts to help states set up the exchanges funded by the legislation."

Despite these very rational reasons for supporting just one pillar of a very unpopular law, that position has "gotten us sideways with some conservatives," McKeown admitted to Politico.

"Leavitt’s status as one of the few Republicans supporting Obamacare implementation has been a matter of significant concern for those on the right, as he and his consultancy represent the most prominent figures in the party urging states to bow to Washington’s wishes," wrote RedState.com columnist Ben Domenech. "Thankfully, most Republican legislatures and governors have rejected Leavitt’s approach outright.”

[Podcast: The uncertain future of health insurance exchanges.]

Leavitt (pictured at left), wrote the Washington Examiner's Philip Klein, is "exactly the type of Republican the Tea Party was founded to oppose.”

The Cato Institute's Michael D. Tanner, meanwhile, wrote about l'affaire Leavitt in a column with an ominous headline: "Dark clouds hang over Romney campaign."

Still, for another perspective, there are those who for the life of them can't figure out what all this hue and cry is about. "It makes absolutely no sense," Greg Pason, national secretary of the Socialist Party USA told the AP earlier this month. Obamacare, "is anything but socialist,” Pason said. “It's bailing out for-profit companies."

Romneycare’s road to vogue
I was living in Massachusetts when Romneycare was signed into law. It was not popular. At least not at first. At least not with those Bay State residents, often young people, who suddenly realized that they'd be forced to buy health insurance with their meager incomes, or else be fined.

My job back then was as a staff writer for the city's alternative newsweekly, the Boston Phoenix. And after Romneycare (as no one called it at the time) went into effect, one of my stories went looking for reaction to the law from a demographic – twentysomething bike messengers, waitresses, etc. – that the media often ignore.

[Political Malpractice: Will health IT bipartisanship survive the elections?]

Despite the fact that Romney's administration set up an independent public authority, the Commonwealth Health Insurance Connector Authority (a.k.a the Health Connector) to essentially be a broker, helping folks without coverage find a plan that fits them and their income, many of these young – and often very liberal – people were ticked off about the "individual mandate" and objected to the plan on general principle.

"@#$% ’em," said one guy I interviewed. "I don’t care."

Back then, I wrote that Romney's "groundbreaking" legislation had the "potential to momentously influence the national insurance debate." Little did I know I'd still be writing about it five years later – not to mention that the governor who signed it into law with that huge grin on his face would be doing everything possible to distance himself from it.

It's ironic. Since 2006, the Massachusetts health reform "has been successful,” Gruber says. “Our law had two goals: One was to cover the uninsured, and we've covered about two thirds of the uninsured, and the other was to fix a broken non-group and non-employer insurance market, and in that market we've cut our premiums in half, relative to national trends."

What the legislation hasn't done is control costs. "Overall healthcare spending in Massachusetts has grown at just about the national average since we passed our law – but that wasn't a goal of the law,” Gruber points out. “So we've done what the law was supposed to do and haven't done what the law wasn't supposed to do."

Moreover, he says, "We've done it with very broad public support. We have about two thirds public support in Massachusetts."

I mention the defiant reactions I got when I wrote that article five years back; the people who angrily rejected the law's mandates.

"I was worried about that too," Gruber says. "It's been a real accomplishment of the Connector and its administrative staff and its media staff to explain to people why it's necessary."

Obama not avowing ACA benefits
If there's one thing the Obama administration has not done well, it's explaining to people why the Affordable Care Act is necessary, or which benefits they are already enjoying.

Gruber admits he was "surprised" by the sound and fury, the wailing and gnashing of teeth that greeted the Obamacare law he helped devise.

"I knew there would be opposition," he says. "I'm surprised that the politics haven't been able to break through more on the benefits for people. But the benefits have to take place. People have to be able to see them and touch them before they believe in them."

So if Romneycare is working as advertised after five years on the books, how will Obamacare be working half a decade after its key provisions take effect in 2014?

"I think it's going to be very successful," Gruber says. "I don't know if it's going to be as successful [as Romneycare has been in Massachusetts]. Partly, it won't cover as many uninsured, because the ACA doesn't cover illegal immigrants and Massachusetts doesn't have many of those."

[Q&A: A public hospital CEO's concerns about SCOTUS, November elections.]

The big issue, however, will still be opposition to the mandate. "My one worry is that even if it passes the Supreme Court, and even if Obama is reelected,” Gruber continues, “the biggest threat is going to be on-the-ground opposition to the law, and opposition to the mandate could undermine it."

Gruber expects the law to be upheld by the Court, "because it's the right thing to do."

But there's no question that by the time you read this article, SCOTUS may have already made this whole conversation moot by striking down the law.

If that happens, "I think we're going to retrench. We ran that experiment in 1994 [with the Clinton healthcare plan],” Gruber says. “With little incremental expansions we'll keep piddling along, but I think it just gets harder and harder to do it. Every time it gets killed, it gets harder and harder to move forward."

Related Political Malpractice coverage:

Health costs highest on Americans' top 10 issues list

Are politics extinguishing state health insurance exchanges?

They all chant 'ACA repeal' but what could a GOP president actually do?

Podcast: SCOTUS and ACA, what we know, what we don't, why each matters

Newt Gingrich on health IT: Then, now, and the days between

For more of our politics coverage, visit Political Malpractice: Healthcare in the 2012 Election.