In yesterday’s Power Point presentation, Mitt Romney argued that each state should have the right to develop its own health care plan and promised to “restore to the states the responsibility and the resources to care for their own poor, their own uninsured, and their own chronically ill.” “States of course will experiment and learn from one another and they’ll have flexibility to deal with the uninsured in the way they think is best,” he said.

But he also introduced the idea of allowing insurers to sell policies across state line, a concept that would allow companies to circumvent state consumer protections and regulations and essentially undermine state powers. As Aaron Carroll explains:

His Massachusetts plan would fail completely if residents of that state could purchase plans from other states, according to other regulations. If New York wants to set community ratings (as should be their right by Gov. Romney’s former argument), then allowing healthy people to buy policies from Texas where no such regulations exist (as should be their right by Gov. Romney’s latter argument), causes New York to fail.

Letting people buy policies across state lines means that states will be regulated by other states – likely the ones with the least restrictions – instead of the federal government. But they won’t be “laboratories” or have real power.

In other words, it’s the same thing that happened after a pair of Supreme Court decisions deregulated the banking industry: credit card companies relocated to states with no interest rate caps and charged what they wanted to borrowers in states with interest rate limits. That’s why all of your credit cards are from Delaware or South Dakota and why companies have used pricing practices that local laws prohibit.

ThinkProgress filed this report from Nashua, New Hampshire.

On Tuesday, 42 freshmen Republican members of Congress — who were largely elected by misrepresenting the Affordable Care Act and its effects on the Medicare program — sent a letter urging President Obama to abandon so-called “Mediscare” tactics against Rep. Paul Ryan’s (R-WI) budget. “We ask that you stand above partisanship, condemn these disingenuous attacks and work with Congress to reform spending on entitlement programs,” reads the letter. Democrats have argued that Ryan’s budget would essentially end the program for future retirees, who would be forced to purchase coverage from private insurers.

Last night, speaking to the Nashua Republican City Committee in Nashua, New Hampshire, potential presidential candidate Rick Santorum (R-PA) took the ‘Mediscare’ argument a step further, sarcastically mocking Democrats for claiming that Ryan’s plan would kill Medicare before mischaracterizing the Affordable Care Act as a “government takeover”:

- SANTORUM SAYS DEMOCRATS SCARE SENIORS: “Listen to their response to Paul Ryan’s budget. ‘Oh! Seniors! Seniors! Vouchers! Oh my goodness! Seniors are going to be thrown out on the streets, they’re not going to be able to get health care! All we’re talking about is instead of a government-run health care system, giving seniors the right to go out and buy insurance by themselves.”

- SANTORUM SCARES SENIORS: “Oh no, we can’t trust seniors. No, no we can’t do that. We have to have Obamacare. Why? Because we can’t trust people to go out and provide for their own health care. We have to have the government tell you what health care you have, what insurance, what markets, everything. Very prescriptive.”

Watch it:

In reality, while the Ryan plan would end the traditional Medicare program for future seniors beginning in 2022 and provide them with “premium support” that would not keep up with health care costs, the Congressional Budget Office (CBO) predicts that far from the government “telling” Americans what they must do, most families will continue receiving their coverage from their employers while the uninsured will have a choice of regulated insurers from the state-based exchanges.

As Paul Krugman notes in today’s column, unlike the GOP, “the Democrats aren’t engaging in scare tactics, they’re simply telling the truth. Policy details aside, the G.O.P.’s rigid anti-tax position also makes it, necessarily, the enemy of the senior-oriented programs that account for much of federal spending.”

The conservative Heritage Foundation is very, very upset that the Obama Administration pointed out their many, many years of support for a requirement that all Americans carry health insurance in a brief defending the Affordable Care Act. So upset, it turns out, that they filed an amicus brief informing the court that they have completely flip-flopped on their longstanding support for such a requirement:

Yesterday, The Heritage Foundation filed a friend-of-the-court brief with the 11th Circuit U.S. Court of Appeals, reiterating Heritage’s opposition to the individual mandate that is a key piece of the Obamacare statute. This is the first time we have ever filed such a brief—as far anyone around here can remember. But we had no other choice. In its merits brief before the appeals court, the U.S. government quoted a 21-year-old statement by a Heritage Foundation policy expert supporting an individual mandate for health insurance, when Heritage’s view today is to the contrary. . . .

For a research organization such as ours to be intellectually honest, we cannot rigidly accept an idea presented decades ago, and ignore empirical evidence presented since. That is why we changed our position on individual mandates long before President Obama ever spoke of one.

Heritage was one of the earliest champions of a minimum coverage requirement like the one in the Affordable Care Act — endorsing this proposal as early as 1989. One of their vice presidents testified in support of this requirement as recently as 2003. The earliest example Heritage cites in its brief of them reversing their longstanding position on health reform is a 2008 article published after Democratic presidential candidate Hillary Clinton had prominently endorsed Heritage’s previous stance.

Moreover, Heritage’s claim that they flip-flopped because of “empirical evidence” is difficult to believe. Their brief lists five reasons why they suddenly stopped believing in an minimum coverage requirement after that position was endorsed by a leading Democrat, but many of them are nothing more than platitudes such as “[o]n philosophical grounds, policymakers should retain a bias for personal liberty.” The only empirical study they cite explaining their position is a mostly irrelevant study showing that more people will participate in 401k programs if they are automatically enrolled in them.

If Heritage actually believes that this study has implications for health insurance policy, however, then they have no business providing advice to federal judges. The reason why an insurance coverage requirement is necessary is to prevent something known as “adverse selection.” The ACA prohibits insurance companies from denying coverage to persons with preexisting conditions, but this ban cannot function if patients are free to enter and exit the insurance market at will. If patients can wait until they get sick to buy insurance, they will drain all the money out of an insurance plan that they have not previously paid into, leaving nothing left for the rest of the plan’s consumers.

In other words, people who wait until the last minute to buy health insurance force other people to pick up the costs of their care. People who wait until the last minute to plan for their retirement, by contrast, bear the cost of their own irresponsibility upon their own shoulders. Accordingly, Americans have far fewer incentives to delay planning for retirement than they do to delay buying health insurance, and thus are more likely to change their behavior because of a gentle “nudge” such as an automatic enrollment program.

Sadly, Heritage’s embarrassing defense of its politically expedient flip-flop is emblematic of their shoddy policy research. Last month, Rep. Paul Ryan (R-WI) relied on a Heritage Foundation analysis to claim that his Medicare-eliminating budget would produce shocking low unemployment and equally unbelievable economic growth. After the Center for American Progress pointed out that Heritage’s projections “are not just overly optimistic, they are impossibly optimistic,” Heritage was forced to print a correction indicating that they had made a basic math error that led to their impossible claim that Ryan’s draconian budget would cause unemployment to drop to 2.8 percent.

Mitt Romney may have have had a tight rope to walk when it came to his support for the individual health insurance mandate, but he pulled no punches with his 2010 campaign health care plan. The proposal is almost identical to the initiative he had offered just two years earlier — it’s boilerplate of GOP health policy.

And like most Republican schemes — which seek to lower health care costs by deregulating the insurance market and opening it up to greater competition — Romney’s plan wouldn’t provide adequate coverage to people with pre-existing conditions or anyone else with a chronic disease who would likely be denied insurance in a true free market structure. He addresses that concern by establishing state-based high risk pools that would provide coverage for anyone denied insurance in the individual market and takes some very small steps to prohibit companies from discriminating against people with pre-existing conditions. Romney would repeal the broad prohibition against denying coverage to individuals with pre-existing conditions that’s already in law (thanks to the Affordable Care Act) and replace it with a limited protection that would not, as Romney put it, necessarily cover an uninsured American who just had a heart attack:

ROMNEY: Couple of common failures I’d go after. Ensure that individuals with pre-existing conditions who are continuously covered for some specified period may not be denied coverage. So you’re not going to say to somebody if you’ve never had insurance and you’re age 55 and you suddenly had a heart attack and now you want to buy insurance, you don’t say to them ‘oh fine you get it.’ That doesn’t work very well. You say instead ‘if you’ve been insured for 10 years and you have a heart attack and you’ve changed jobs because of that continuous period of insurance of course you will continue to be covered.

Watch it:

As Romney himself recognized in Massachusetts, insurance reforms don’t work very well unless you can encourage everyone to participate in the health insurance market and eliminate “free riders” who would only purchase coverage when they need it. Insurance protections and the individual mandate go hand-in-hand, as establishing one without the other leads to a very substantial spike in premiums. Romney tries to prevent that from happening by setting “some specified period” during which individuals “may not be denied coverage.” But a better way ensure that people have access to insurance before that “sudden heart attack” (and maybe even to prevent it) is to do what Romney has already done in Massachusetts — pair a pre-existing conditions exclusion with an individual mandate.

This morning, Massachusetts Gov. Deval Patrick (D) responded to Mitt Romney’s health care PowerPoint presentation by saying, “to listen to Governor Romney it sounds like he likes everything about the Affordable Care Act except for the fact that it was signed by President Obama.” Patrick defended Romney’s signature health care law during his morning appearance on MSNBC and even suggested that the GOP presidential front-runner was responsible for convincing him to support the plan’s individual mandate:

TODD: Mitt Romney was the guy talking about mandates and he said — he embraced them a lot with a lot more gusto than he did yesterday. Candidate Obama didn’t like mandates. How did you change his mind on this?

PATRICK: Well, I’m not sure I did, because I started out skeptical of mandates as well, Chuck. You know, going back now six or seven years when we were still debating our health care reform here and when I was a candidate. That issue was being debated here it seemed — I was uncomfortable with it. I came to understand, listening to Governor Romney and the other business people and others who were involved with it that this is really a kind of classic insurance theory which is you spread the risk as widely as possible and keep costs down for everybody.

Watch it:

Indeed, when Romney first unveiled his health care plan in 2005, he said he came to support the individual mandate as a means of reducing “free riders” — uncompensated care for the uninsured — in the state’s health care system. “It’s the ultimate conservative idea, which is that people have responsibility for their own care, and they don’t look to government to take of them if they can afford to take care of themselves,” he told the Boston Globe on June 22, 2005.

“What I am saying is if you can afford insurance and don’t get it, and you can afford care and you don’t pay for it, it is no longer appropriate for you to just pass that on to someone else,” he added.

During his series of 19 town halls in Wisconsin several weeks ago, Rep. Paul Ryan (R-WI) repeatedly criticized President Obama’s Independent Payment Advisory Board (IPAB) for “rationing” care to seniors, cutting Medicare, and denying care to current retirees. The IPAB is a 15-member commission that would make recommendations for lowering Medicare spending to Congress if costs increase beyond a certain point. The reductions would go into effect unless Congress acts to stop them.

“[Obama's] new health care law…puts a board in charge of cutting costs in Medicare,” Ryan told retirees at one town hall in Kenosha, Wisconsin in late April, arguing that the IPAB would “automatically put price controls in Medicare” and “diminish the quality of care for seniors.”

But as the Incidental Economist’s Don Taylor reports this morning, Ryan has previously introduced legislation that included a very similar board to control health care spending. In 2009, Ryan introduced the Patients’ Choice Act (PCA) which “proposed changing the tax treatment of private health insurance and providing everyone with a refundable tax credit with which to purchase insurance in exchanges” but also sought to establish “two governmental bodies to broadly apply cost effectiveness research in order to develop guidelines to govern the practice of, and payment for, medical care.” Taylor writes that “the bodies proposed in the PCA had more teeth, including provisions to allow for penalties for physicians who did not follow the guidelines, than does the Independent Payment Advisory Board (IPAB) that was passed as part of the Affordable Care Act.” Both the Health Services Commission and Forum for Quality and Effectiveness in Health Care was tasked with developing guidelines and standards for improving health quality and transparency and were afforded what the bill called “enforcement authority”:

(b) ENFORCEMENT AUTHORITY.—The Commissioners, in consultation with the Secretary of Health and Human Services, have the authority to make recommendations to the Secretary to enforce compliance of health care providers with the guidelines, standards, performance measures, and review criteria adopted under subsection(a). Such recommendations may include the following, with respect to a health care provider who is not in compliance with such guidelines, standards, measures, and criteria: (1) Exclusion from participation in Federal health care programs (as defined in section 1128B(f) of the Social Security Act (42 U.S.C.1320a–7b(f))).(2) Imposition of a civil money penalty on such provider

Like the IPAB, Ryan’s board is insulated from Congress and would have allowed true health care cost experts — the Forum for Quality and Effectiveness in Health Care even included 15 individuals, just like the IPAB although they do not appear to require Senate confirmation — to improve the cost effectiveness of the health care system. As Taylor observed back in 2009 when the board was first introduced, “any such effort will undoubtedly be called rationing by those wanting to kill it, and quality improvement and cost-effectiveness by those arguing for it. Whatever we call it, we must begin to look at inflation in the health care system generally and in Medicare in particular.” Little did we know that Ryan would be on both sides of that debate.