The Republican Who Thinks Big on Health Care

By Joe Klein

Governor Mitt Romney is a Massachusetts politician with a long, narrow face, an impossible shock of hair and presidential ambitions. He's also pretty tall. But any resemblance to another recent Massachusetts politician who ran for President evaporates the moment Romney opens his mouth: his demeanor and metabolism are the opposite of John Kerry's--informal, conversational, enthusiastic and speedy. Or maybe it was just that we were talking about his rather remarkable plan to bring mandatory universal health-care coverage to Massachusetts by next summer, the first time a Republican has tried to pull off this most Democratic of policy goals.

"I don't like calling it universal coverage," he told me last week. "That smacks of Hillarycare. But I do think we've come up with a way to get everybody covered through the free-market system." Romney's way is not new: policy wonks call it an "individual mandate" system, but the Governor doesn't like that term either. "I call it a personal responsibility system," he said.

Here is how it would work. Massachusetts now spends about $1 billion a year to provide emergency health care for at least 500,000 uninsured citizens. About 200,000 of those are young people, predominantly male, who are making enough money to buy health insurance but figure they don't need it. They would be required to buy a relatively inexpensive health insurance policy, with higher deductibles and co-pays--that's where the "mandate" comes in. Another 100,000 are extremely poor people who are eligible for Medicaid; a concerted effort would be made to bring them into the system. The remaining 200,000 are the people who have been most neglected by the system in the past: the working poor, people who have low-end service jobs or work part time for employers who don't offer health coverage.

Romney's gamble is that Massachusetts can take the $1 billion it spends on the uninsured and use it to subsidize coverage for the working poor. The Bush Administration will kick in another $1 billion, over three years, to make the experiment work if Romney can get a suitable proposal through his state legislature. "Our plan would cost the poorest eligible families only about $2 per week in premiums," Romney said. "The more you earn, the more you pay." Sounds simple enough. So why hasn't it been tried before? Because interest groups on the left and right hate the idea. Conservatives don't like the mandatory part: if a 28-year-old software designer doesn't want to buy health insurance, why should the government force him to do so? Simple answer: fairness. The rest of us pay for it now when he drives his motorcycle into a tree and runs up a huge medical bill. Health insurance should be no different from auto insurance, a basic civic responsibility. There's also a larger argument for the common good: the more healthy young people are paying into the system, the lower the premiums for everyone else. But Democrats, skittish since the Clinton proposal was trashed in 1994, have refused to call for an individual mandate. In the past two presidential campaigns, Bill Bradley, John Kerry and Howard Dean proposed comprehensive health plans, but fearing the political consequences, none of them required software-designing motorcycle riders to kick in.

On the left, activists dislike an individual-mandate system because it relies on the ability of poor people to navigate the complexities and uncertainties of the free market. Some favor a government-funded system like those used in Canada and Europe. Others, realizing that socialized medicine just won't fly in the U.S., support an "employer mandate" similar to the program that Clinton proposed in 1993. "Why shouldn't low-end service companies that provide little or no health insurance for their workers now, be forced to kick in?" asks John McDonough, of the advocacy group Health Care for All. "They're not going to move to China." Fair point, except for one minor detail: if new costs are forced upon private companies, they'll just pass them along to consumers ... and maybe tack on a couple of extra pennies of profit in the process, blaming the higher prices on liberal politicians who want socialized medicine. Other critics of Romney's plan fear it will ultimately cost more than advertised and the working poor won't receive sufficient care. "They may be right," the Governor told me. "Or it may cost less, if people start getting the proper preventive care. We'll have to see how it works, and make adjustments over time."

Indeed, Romney's plan seems a plausible compromise between the Massachusetts senate, which passed a bill that isn't mandatory and therefore doesn't cover all the uninsured, and the house, which passed one that requires both an individual mandate and a tax on employers that don't provide health insurance. "The Bush Administration isn't going to give us $1 billion for a 'demonstration' project that doesn't demonstrate how to cover everyone," the Governor said, "and it certainly won't favor one that taxes employers." A deal must be cut soon, or the federal money will be lost. "I'm optimistic," Romney said. "Ted Kennedy told me last week he wants to be there for the bill signing."