Heritage to Mitt Romney to President Obama: The disputed origins and outcomes of health care reform

Published: Tuesday, Oct. 2 2012 11:00 p.m. MDT

Protesters chant in front of the Supreme Court in Washington, Wednesday, March 28, 2012, as the court concludes three days of hearing arguments on the constitutionality of President Barack Obama's health care overhaul, the Patient Protection and Affordable Care Act. (AP Photo/Carolyn Kaster)


When Mitt Romney faces off against President Barack Obama tonight in the first of three presidential debates, some of his former rivals may be saying, "I told you so."

During the primaries, Romney's challengers attacked his Massachusetts health care reforms — focusing mainly on the individual mandate, which they argued inspired a key feature of Obamacare.

Rick Santorum led the attacks, arguing that the mandate link compromised Romney and he would be poorly positioned to attack Obamacare as a result.

The irony is that the individual mandate has deep conservative roots. There are key differences between what Romney first proposed and what Obamacare became — differences with disputed implications. But when it comes to individual mandate itself, left and right originally saw more eye to eye.

How the GOP ended up with a candidate whose signature policy achievement is thought to handicap his campaign efforts is a fascinating story in policy development and partisan politics.

The uninsured Porsche

When Romney brought the individual mandate to Massachusetts, he followed the lead of the Heritage Foundation, a staunchly conservative think tank, which saw it as a free market alternative to government-run health care.

Decades ago, Heritage helped lay the intellectual foundations of the Reagan Revolution with detailed conservative policy analysis. But by 1989, health care costs were rapidly climbing, jumping from 9 percent of GDP in 1980 to 12 percent in 1989 — on its way to 17 percent today, and still climbing.

As costs rose, health care availability became iffy for the working poor or the self-employed, pressures that burst out in the bitterly fought Clinton health care push of 1993 and 1994.

The Heritage Foundation had anticipated this fight in 1989, offering a plan to solve critical health care cost and availability problems without top-down federal control.

As Topher Spiro at the liberal Center for American Progress noted, the Heritage Foundation offered its plan at a time "when they were certain that a government run, single-payer system was on its way." The Heritage proposal, he said, "relied on private markets but allowed government intervention to correct market failures." This is the basic framework of Obamacare, Spiro concludes.

The Heritage plan had two simple foundations. First, it argued that American society would not leave people to die in the streets. Second, it insisted that we could not allow the uninsured to shift costs to others.

"If a young man wrecks his Porsche and has not had the foresight to obtain insurance, we may commiserate but society feels no obligation to repair his car," read a 1989 Heritage Foundation report.

"But health care is different," the report continues. "If a man is struck down by a heart attack in the street, Americans will care for him whether or not he has insurance. If we find that he has spent his money on other things rather than insurance, we may be angry but we will not deny him services — even if that means more prudent citizens paying the tab."

The Heritage plan offered three policy strategies: expand Medicaid for the very poor, offer tax credits for lower and middle incomes and use an individual mandate to force free-riders to join up. All three of these elements eventually entered into Romney's reforms — and from there moved into the 2010 Obamacare legislation.

Insurance in name only

During the 1990s, a handful of states from Maine to Washington experimented with simpler but ill-fated reforms. One tactic simply barred insurers from denying coverage based on pre-existing conditions. Another forced insurers to charge roughly equal premiums to both the young and the old.

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