Tuesday, February 12, 2013

The Massachusetts Avenue of health reform

In contrast to the personality-driven path that Lyndon Johnson took to navigate legislative obstacles to Medicare and Medicaid, former management consultant Mitt Romney charted a decidedly different course to expanding health insurance when he became governor of Massachusetts in 2003. This month's Georgetown University Health Policy Seminar explored the politics of "Romneycare," a state-level health reform which in many ways made possible the future Affordable Care Act. Both readings for this session, a New Yorker article and a Health Affairs paper, portrayed Romney as a “data wonk” who viewed the issue of the uninsured as a problem-solving challenge rather than a grand moral imperative. Yet much like LBJ's inspirational leadership, Romney's data-crunching approach produced tangible results.

Governor Mitt Romney signs the Massachusetts health reform bill as Ted Kennedy looks on.

In an Op-Ed about his nascent reform plan that appeared in the Boston Globe in November 2004, Governor Romney proposed applying "carrots and sticks" to persons who could afford private health insurance but had chosen not to purchase it. At that point, he had not yet committed to the individual health insurance mandate that made his reforms possible but later became a political liability during his Presidential campaigns. According to New Yorker columnist Ryan Lizza:

Romney and his aides had a lengthy debate about the merits of the mandate, which evolved into a broader philosophical discussion. Personal responsibility was important, some aides argued, but what about the libertarian view that the government had no business requiring people to buy something? It was one thing to ask drivers to buy car insurance. Owning a car is a choice. But the health-insurance mandate demanded the purchase of a product just for being alive.

Once he made the decision to incorporate the individual mandate into his reform plan, Governor Romney found an unlikely ally in Senator Ted Kennedy, whom he had tried unsuccessfully to unseat in 1994. Together, Romney and Kennedy approached the George W. Bush Administration and reached an agreement to redirect a multi-million dollar fund for Massachusetts hospitals to provide subsidized health insurance for lower income workers. Romney also alternately courted and cajoled the Democratic leaders of the Massachusetts legislature, whose support was essential to passing his plan.

Health reform in Massachusetts has been judged a mixed success. On one hand, the percentage of state residents who were uninsured fell from 6.4% in 2006 to 1.9% in 2010, as the national average rose from 15.2% to 16.3%. However, Romney's hope that insurance expansion would help control costs has not been fulfilled, as the percentage of the state budget spent on health services has risen from 29 to 43 percent.

Compared to the policy environment that confronted President Barack Obama in passing the Affordable Care Act, seminar participants identified some key advantages for Romney: Massachusetts's already low uninsurance rate provided a "fertile environment" for reform, and he could focus his attention on health care without having to simultaneously manage financial crises and war. Although Romney "had little choice as governor about grappling with health care," wrote Martha Bebinger in Health Affairs, "for the most part he embraced the issue. Aides say Romney was enticed by the challenge of solving a complex problem, one that had eluded politicians for decades." How critical do you think Romney's public embrace of health reform was to the law's eventual passage? Was it as important, for example, as LBJ's advocacy for Medicare?

-  Kenny Lin, MD
   Director, Robert L. Phillips, Jr. Health Policy Fellowship
   Department of Family Medicine
   Georgetown University School of Medicine

1 comment:

  1. Plato, in "The Republic", is often considered the first Western philospher to espouse the idea of enlightened despotism- absolute rule under the auspice of a "philospher king" (think Frederick the Great, Tito or Ataturk). This model of government provides for the efficient application of the law under a monarch, but protects the rights of the people through the inherent philosopher, beneifience of an enlightened, compassionate ruler. Interestingly, Plato felt this form of government was untenable as too often absolutism devolves into tyranny and usurps the needs of the people. Over the centuries, constitutional law and the development of checks and balances in representative democracies have evolved to protect the people from the capricious will of self interested legislators and executives. But this too presents and interesting challenge with respect to beneficience. Churchill said "Democracy is the worst form of government, except for all those other forms that have been tried from time to time", and in order to "give the people what they deserve" (Aristotle's definition of a righteous government), modern politicans must navigate the contentious milieu of their fellow, unlike minded colleagues. LBJs ability to create consenus around the formation of Medicare is testament to his coalition building skills. Changes that come from cultural consensus are often longer lived than those that come by fiat. But what happens to policy changes (such as Mr. Romney's) that are dervived from the desire to improve upon real issues and are evidenciary in their construction? Such tactics are not dissimilar to Mr. Obama's use of a democracticly controlled Congress in passing the Affordable Care Act (ACA). Often these policy changes are met with populist consternation and political backlash, but if they survive short term repeal, are enacted and ultimately embraced for their positive effects (should they have any), they too seem to become such as permanent a part of the policy landscape. Perhaps the relative value of either approach depends on the immediate political reality faced by the change agent(s). In the case of LBJ, his push required consensus building, but in more liberal Massachusetts or 111th Congress, a rapid policy push could be just as effectual. Of course, the latter assumes a level of intellect policy making and evidence based beneficience that the people will ultimately feel, otherwise longer term political oppposition may still be the death knell of any such derived policy.

    Matthew Burke, MD
    Family Medicine
    Franklin Square Hospital