Romney And His Argument For A ‘State-Based’ Health Reform Solution


Greg Sargent is giving Mitt Romney the benefit of the doubt on his support for state-based health care reform, pointing to this quote from a 2007 speech that seems to suggest that Romney has always argued for a state-by-state solution:

A one-size-fits-all national healthcare system is bound to fail. It ignores the very dramatic differences between states and it relies on a Washington bureaucracy to manage. You think about this, I do not want the guys that ran the Katrina clean up running our healthcare system. So in my view, healthcare reform has to take a federalist approach … We let states decide how they craft their own program. States are able to craft programs to match their unique needs and of course we let states remain as the laboratories of innovation. And by the way, I like the plan we came up with in Massachusetts. I wouldn’t be surprised if other states say, `I like that way, I’m going to copy it.’ And I’d be proud if they did. Some states will find they’ve got better answers than what we came up with, and if they do, hats off to them.

Putting aside Romney’s 2009 comments that Massachusetts reform should serve as a “model” for extending coverage to the nation (which Greg reported on yesterday and I’ve written about here, here, and here), I think the more troubling aspect of this quote isn’t Romney’s position, but the false implication that the Affordable Care Act is a “one-size-fits all national health care system” that does not recognize “very dramatic differences” between the states. In other words, even if Romney has been consistent in his stance, his characterization of the law is self-serving and dead wrong.

In reality, while the ACA lays out a certain framework stats have to follow — there is no question about that — it still provides governors with a great deal of flexibility in how they implement reform, allowing each state an opportunity to develop a somewhat unique solution. Even the waivers HHS is granting to some states (but mostly businesses) is an acknowledgment of the fact that states have what Romney describes as “unique needs.” As Tim Jost recently observed on the Health Affairs blog:

The states, for example, have the option of either implementing the health insurance exchanges themselves or allowing the federal government to do so. States may establish their own risk adjustment programs, preexisting condition high risk pools, and excessive premium increase review programs or leave these tasks to the federal government.

The states also have the option of either enforcing the ACA’s basic insurance regulatory reforms (the ban on rescissions, the requirement of coverage for adult children and of preventive services without cost-sharing, and others), or letting the federal government do it. If a state chooses to implement the law itself, moreover, it generally has a great deal of flexibility in the approach it takes to implementation, as we are witnessing currently in the widely varying approaches the states are taking to establishing their exchanges. […]

The greatest flexibility, however, is provided by section 1332. This provision authorizes the Departments of Health and Human Services and Treasury to waive key provisions of the ACA and to provide block grants in the amount that the federal government would otherwise have spent in a state on ACA tax credits to states that develop their own innovative proposals for reforming health care. Regulations to implement this provision were proposed on March 10, 2011.

So the more honest position would be to drop the pretense of ACA rigidity and propose different ways to allow states even greater flexibility, if that’s what Romney believes would solve the health care crisis. But those kinds of solutions would require actual policy proposals that don’t lend themselves to the candidate’s one-liner zingers and soundbites.