'Three Cheers for Romneycare'

Jennifer Rubin, the Washington Post‘s resident Romney campaign mouthpiece, has been joined by another conservative pundit in the “I left my dignity at the altar of Mitt Romney” club. This time, as you may have heard, the offender is Ann Coulter, whose support for the former Massachusetts governor (and lack of publicity to date leading up to her CPAC appearance next week) has led her to offer – in print – a full-throated (albeit screechy) defense of the biggest piece of baggage Romney possesses: the Massachusetts Health Care Reform Act of 2006, or ‘Romneycare.’

Coulter’s column, titled “THREE CHEERS FOR ROMNEYCARE!” (yes, the title is all caps in the original), provides a defense of Romneycare that simply and completely ignores both conservative objections and the reasons why it has been a dismal failure as policy. For example, she drops the names of people and organizations that supported it at the time, despite the fact that such supporters were few and far between (opposition was much more commonplace), and that many of those supporters have since publicly changed their minds. An example of this is her declaration that “A leading conservative think tank, The Heritage Foundation, helped design Romneycare, and its health care analyst, Bob Moffit, flew to Boston for the bill signing.” Fine – but what Coulter ignores is the fact that Heritage has since repudiated the idea of an individual mandate at any level, writing in an amicus brief (pdf) filed in a challenge to Obamacare that “since [the passage and implementation of Obamacare], a growing body of research has provided a strong basis to conclude that any government insurance mandate is not only unnecessary, but is a bad policy option.”

Where she does acknowledge the obvious issues with Romneycare, Coulter simply throws mud at “Democrats” for ruining Romney’s beautiful program. She writes:

What went wrong with Romneycare wasn’t a problem in the bill, but a problem in Massachusetts: Democrats.

First, the overwhelmingly Democratic legislature set the threshold for receiving a subsidy so that it included people making just below the median income in the United States, a policy known as “redistribution of income.” For more on this policy, see “Marx, Karl.”

Then, liberals destroyed the group-rate, “no frills” private insurance plans allowed under Romneycare (i.e. the only kind of health insurance a normal person would want to buy, but which is banned in most states) by adding dozens of state mandates, including requiring insurers to cover chiropractors and in vitro fertilization — a policy known as “pandering to lobbyists.”

Philip Klein has deals with this claim appropriately at the Examiner:

This is more silliness. To start, Romney signed the health care law with a smiling Ted Kennedy at his side knowing that Democrats had the votes to override any symbolic line-item vetoes of certain provisions. Furthermore, when he signed the law, he had already announced he wasn’t seeking reelection as governor and knew that it would almost certainly fall on Democrats to implement the law. Part of being a limited government Republican is realizing that once you put the infrastructure in place, successors can always add to it.

Regardless, what he actually signed was bad enough.

Additionally, Coulter puts her derision for members of the conservative movement on full display by declaring that the only reason opposition to the law exists is because the nickname ‘Romneycare’ sounds like ‘Obamacare.’ Seriously.

Of course, that’s not the issue at all – nor is the issue whether or not Romneycare is ‘constitutional’ according to the guiding documents of the United States or of the Commonwealth of Massachusetts, a straw man Coulter spends the remainder of her column arguing against.

The problems with Romneycare are plenty without adding straw men to the list. Access to insurance has been increased (as have the penalties for not purchasing it). thanks in no small part to Massachusetts’ ability to stick the federal government and national taxpayers with a hefty portion of the program’s tab, but insurance is not care – a fact many casual participants in the health care debate conveniently ignore. The price of care and treatment has skyrocketed, causing the Office of the Attorney General to declare that government price controls (including the requirement that patients pay the difference out of pocket if they see a provider that charges more than the government-approved rate) must be implemented a quickly as possible to stem the rising tide.

The Beacon Hill Institute found that, between Romneycare’s 2006 implementation and 2011:

  • State health care expenditures have risen by $414 million over the period
  • Private health insurance costs have risen by $4.311 billion over the period
  • The federal government has spent an additional $2.418 billion on Medicaid for Massachusetts
  • Over this period, Medicare expenditures increased by $1.426 billion

Problems abound besides just these key points, but to understand them in their proper context, it’s important to address just what Romneycare’s three-pronged approach to dealing with the “problem” of the state’s uninsured population, which was relatively low at the time (about 550,000 according to state figures, and 657,000 according to the U.S. Census Bureau), consisted of.  Some of the numbers below reference FY 2008 because a portion of this description comes from an analysis I wrote in 2009, when the program was being used as a blueprint for Obamacare.

First, Romneycare expanded subsidies for low-income (below 300% of the federal poverty line) residents to obtain health insurance. While this sounds like a valuable benefit being provided to indigent Massachusetts residents, the funding for those subsidies was primarily pulled from the state’s so-called “free care pool,” which had provided medical and mental health services to poor Bay Staters at locations ranging from community clinics to emergency rooms, regardless of their insurance status. As an ironic result of this program, more poor residents had access to subsidized insurance, but fewer could afford care when faced with a deductible and coinsurance – meaning the amount the patient had to pay up front before insurance kicked in, and the percentage of treatment costs past the deductible that fall on the policyholder. The burden of paying for service the Health Care Reform Act placed on the state’s indigent population, combined with the draining of resources from facilities that had previously cared for the poor free of charge, left a larger number of poor Massachusetts residents without access to care than before the system was ostensibly “reformed” to help them gain more affordable access to care.

Second, under the Health Care Reform Act, all businesses with over 11 employees located within Massachusetts were legally required to provide health coverage for their workers or face a fine of $295 per uninsured employee. Besides being a flagrant violation of the federal Employee Retirement Income Security Act (ERISA) – a federal law that, among other things, prevents states from mandating employer benefits – the employer mandate has failed to fulfill its primary purpose in the eyes of those who pushed for its inclusion in the bill: not enough employers opted to pay the fine (rather than offer health insurance to employees) to cover the portion of the program cost ($45 million) that proponents expected. In fact, by Spring of 2008, only $5 million had been collected from businesses that declined to offer coverage to their workers – an amount less than one-half of one percent of the $1.1 billion the program cost state taxpayers that year. The vast majority of the rest of that cost had to be covered by diverting funds from the “free care pool,” which, again, severely limited the indigent population’s access to care.

Third, Romneycare included its famous individual mandate, making the failure to carry health insurance a violation of state law which that is punishable by a four-figure fine.  That fine, collected along with state income tax, essentially operates as an onerous, regressive tax on the uninsured (despite the fact that those who actually file and pay income taxes are statistically the least at risk of being uninsured). The fine can be avoided if an uninsured individual can prove to the state that “no affordable coverage is available” – something that over 20% of the state’s total uninsured have successfully shown, despite promises that the Health Care Reform Act would bring the cost of insurance down to a level that would be affordable by all of the state’s residents.

A new “independent agency,” called the Connector, was established by the state government to oversee the enactment of the employer and individual mandates and the implementation of health insurance subsidies for the indigent population. Along with monitoring compliance with those mandates, the Connector is responsible for determining what insurance policy each resident must enroll in, be they subsidized or paying full price, and for enforcing a rationing of care to those who qualify for subsidized coverage. Benefits for those who are below 300% of the poverty line (thus qualifying for subsidies) are limited by what the indigent individual is able to pay in terms of premium, deductible, and coinsurance, with those at the bottom of the income pyramid often qualifying for such severely restricted coverage that they would have been far better off remaining uninsured and continuing to receive care at facilities funded by the “free care pool.”

While the establishment of an agency to study the relationship between the uninsured and high health care costs and to help those who qualify for state-administered health coverage programs choose the best fit for their circumstances is not a bad idea in principle – Pennsylvania’s Health Care Cost Containment Council is a good example of one that functions well – the Connector has simply become another regulator, on top of the existing Massachusetts Department of Insurance, that gums up the health care market with excess regulation and adds to the cost of health insurance through the surcharges added to premia in order to fund its continued operation.

As with most government-related oversight boards, the Connector has been beset by requests from special-interest advocates, and it has had a very difficult time saying no to many of them. The result has been the imposition of onerous coverage mandates on the insurance policies state residents are now required by law to purchase. With four dozen coverages that are required to be included on every single policy sold within the state, from coverage for the services of nurse midwives to Mental Health Parity (an innocent-sounding mandate that requires mental health to be covered, dollar-for-dollar, to the same level as physical health), insurance premium and health care costs have skyrocketed under the Health Reform Act. Further, the addition of so many mandates actually caused nearly 200,000 previously insured Bay Staters to lose their coverage status because the prescription drug coverage in their private policies was no longer deemed “up to snuff” by the new gatekeeper of health insurance “quality” in Massachusetts.

Massachusetts’s attempt at health care reform has increased the number of insured residents by 443,000 (covering about 66% of those who previously lacked insurance). However, the program has cost far more than predicted ($1.1 billion in FY 2008 and $1.3 billion in FY09), due in part to the fact that over half of those added to the rolls of the insured qualify for some form of subsidy. As the program was hemorrhaging cash in 2008, current Governor Deval Patrick (D) declared that it would be kept afloat at all costs, even though (quite ironically) the only way to continue funding it was to drain money from the public hospitals and community clinics that had already been providing care, under the free care pool, to those who were now appropriating that funding in the form of insurance subsidies. Further, the state’s redirecting of free care pool funding and imposition of caps on reimbursements for care has created an access problem by dramatically reducing the number of providers available to see and treat patients, regardless of whether those patients have insurance or not – a reinforcement of the fact that insurance, even when it is as universally prevalent as a government can make it, does not equal access to care.

Far from reducing the cost of health insurance, Massachusetts’s individual mandate has driven costs up at twice the average national rate. This was entirely predictable; after all, what can possibly reduce downward pressure on a price more effectively than a legal requirement to purchase it, whatever the cost? According to the Connector, the least expensive price for an insurance policy for a 50 year old non-smoker in 2008 was $3,599 a year ($299.94 per month), with a $2,000 deductible. Next door in Connecticut, that price was just $1,468 a year ($122.36 per month, with a $2,500 deductible) – and Connecticut hadn’t even spent $1.3 billion on controlling and engineering their state’s health care marketplace!

The biggest issue with Romneycare from the conservative perspective, though, is simply the massive expansion of government size, control, and intrusion that it represents. Constitutional or not, similar-sounding to ‘Obamacare’ or not, and effective at expanding insurance or not, the Massachusetts Health Care Reform Act is a law which requires individuals living in the Commonwealth to purchase a good or service, allows the state government to decide what an acceptable form of that good or service is and how it can be used, forces healthy individuals into costly high-risk pools to balance out risk and cost (thereby increasing price and severely limiting choice), and demands that residents of Massachusetts and the other 49 states pay an ever-increasing bill to sustain the ever-growing program.  Whether or not you support Mitt Romney, the simple truth is that Romneycare is in no way a conservative program, and is in no way supportable by conservatives. Period.

On a personal note, I’ve had little use for Ann Coulter for some time now. It’s been clear to me for years that Coulter’s only interest and commitment is herself and the publicity she can garner, not conservatism, the conservative movement, or the GOP. One of my RedState colleagues went so far a few years ago as to call her a “detestable harpy,” and while that may not be the most accurate choice of words to describe her, this latest “contribution” to the primary election discussion simply reinforces Coulter’s lack of direction, conviction, or compass outside of her personal gluttony for publicity.

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