The state health reforms overseen by Mitt Romney while he was governor of Massachusetts have received significant attention throughout this campaign season. But the health policy record of the presumptive Republican presidential nominee goes beyond this state law to include a range of hot-button issues — from the future of the federal health law to plans to revamp Medicare and Medicaid costs as well as a range of market-based initiatives –- that will continue to draw attention as the November election approaches.

KHN has assembled this resource to show in detail how these positions are taking shape.

Photo by Alex Wong/Getty Images

On Massachusetts Health Reforms, Romney:

• Was a key player in the effort to reform Massachusetts’ health care system. Before his election as governor, he campaigned on a health overhaul plan that included the following elements: charging co-pays to higher-income Medicaid recipients to expand coverage, requiring employers of more than 10 employees to offer insurance or pay a penalty, extending favored prescription pricing in the state’s drug plan for elderly and disabled residents and negotiating an increase in federal funding for Medicaid. In 2005, he proposed Commonwealth Care, which helped frame the negotiation for health care reforms that ultimately became state law.

• After his term as governor ended, he cited the 2006 state health reform law as a point of pride, but has since distanced himself from it because it is often considered a prototype for the federal Affordable Care Act, an assertion he rejects. The Massachusetts law includes the creation of an online insurance exchange known as the Health Connector, as well as fines against businesses with more than 10 employees that don’t offer health insurance plans and a mandate that all individuals not covered by public health insurance purchase health insurance.

“If somebody could afford insurance, they should either buy the insurance or pay their own way. … We said: If you can afford insurance, then either have the insurance or get a health savings account. Pay your own way, but no more free ride. That was what the mandate did.” – Romney, GOP candidate debate, Jan. 30, 2008

• Defends Massachusetts’ individual mandate because it was a state-level decision — not a matter imposed by the federal government.  

“Mr. President, if, in fact, you did look at what we did in Massachusetts, why didn’t you give me a call and ask what worked and what didn’t? … I would have told you, Mr. President, that what you’re doing will not work. It’s a huge power grab by the federal government. It’s going to be massively expensive, raising taxes, cutting Medicare.” – Romney, GOP candidate debate, June 13, 2011

• Advanced a managed care plan for seniors who are eligible for both Medicare and Medicaid.

• Was silent on a 2005 proposal to extend health care benefits provided by the state government to same-sex couples.

• Proposed tort reform legislation in 2006 that would reduce legal fees and make a hard cap of $500,000 on non-economic damages. Lt. Gov. Kerry Healey led this effort. 

“I like what I proposed in Massachusetts when I was governor. And even though the final bill and its implementation aren’t exactly the way I wanted, the plan is a good model. Today, almost every Massachusetts citizen who had been uninsured now has private, free-market coverage, and we didn’t have to raise taxes or borrow money to make it happen. We may find even better ideas in other states. But let’s make certain that conservative principles are front and center. A big-government takeover of health care is the next thing liberals are going to try, and it’s the last thing America needs” – Romney, CPAC Convention, Feb. 27, 2009.

On Medicare & Aging, Romney:

• Favors Medicare reforms that would give future beneficiaries a “defined contribution” or “premium support” and allow them to choose between private and traditional plans.

• Maintains that seniors already enrolled in Medicare, or those nearing retirement, would not be affected by his plan, which also would retain a fee-for-service option.

“I wouldn’t repeal it. I’d reform Medicare and reform Medicaid and reform Social Security to get them on a sustainable basis, not for current retirees, but for those in their 20s and 30s and early 50s” – Romney, Tampa Tea Party Debate, Sept. 12, 2011.

• All plans would have to offer coverage at least comparable to what Medicare provides today, though premiums for “traditional” coverage would rise if private companies can provide the same services for less. Critics say that capping the government’s contribution would likely mean that beneficiaries’ costs would increase.

• Backed the December 2011 Medicare proposal by Rep. Paul Ryan, R-Wis., and Sen. Ron Wyden, D-Ore.

• Prior to the Ryan-Wyden plan, supported the Medicare overhaul included in the Ryan budget plan that was approved by the GOP-controlled House of Representatives.

• Supports the notion that wealthier seniors should pay more toward their health coverage and lower income seniors should receive a higher subsidy.

• Wants to publish a yearly federal balance sheet to help people understand the impact of entitlement spending on the budget and economy.

On The Health Care Marketplace, Romney:

• Wants to strengthen high-deductible health savings accounts by allowing consumers to use them to pay insurance premiums.

• Supports caps on non-economic damage awards in medical malpractice lawsuits and funds for states to develop other ways to deal with the liability issue, such as health care courts.

• Urges restricting federal regulation of health care insurance, although he supports limited rules to bar insurers from denying coverage to those with preexisting conditions when they have had coverage for a specified period of time.

• Supports “co-insurance” plans, in which consumers pay a fixed percentage of the cost of their care.

• Says insurers should be allowed to sell their products across state lines.

• Endorses ending “tax discrimination against the individual purchase of insurance” and has suggested allowing tax deductions for people who obtain health insurance on their own; also favors allowing individuals and small businesses to join together to buy insurance.

• Wants to issue “Consumer Reports”-type ratings of insurance plans.

“The reason health care is so expensive … is not just because of insurance, it’s because of the cost of providing care. And one reason for that is the person who receives care in America generally doesn’t care how much it costs, because once they’ve paid their deductible, it’s free. And the provider, the more they do, the more they get paid … And so what we have to do is make sure that individuals have a concern and care about how much something costs. And for that to happen [we need] health savings accounts. Give people a stake in what the cost of insurance is going to be, what the cost of it is going to be. Co-insurance, where people pay a share of the bill, that makes a difference.” – Romney, Tampa Tea Party Debate, Sept. 12, 2011.

On Health Reform Philosophy, Romney:

• Says he would allow states to opt out of the federal health law and encourage Congress to repeal it.

• Believes that “each state should be able to fashion their own program for the specific needs of their distinct citizens,” and that states are the “laboratories of democracy.”

• Maintains that “market dynamics” such as increased competition, provider performance ratings, cost comparisons for procedures, co-insurance and lowering the number of uninsured will improve the health care delivery system.

• Endorses efforts to find an alternative to the fee-for-service payment model.

“I want people to be able to own their own insurance, if they wish to. And to buy it for themselves and perhaps keep it the rest of their lives and to choose among different policies offered from companies across the nation,” he said. “That means the insurance company will have an incentive to keep you healthy. It also means, if you don’t like what they do, you can fire them.” — Nashua, New Hampshire, Jan. 9, 2012

On Medicaid, Romney:

• Opposes the health law’s expansion of Medicaid coverage to as many as 17 million people.

• Supports Medicaid block grants to allow states to use capped federal contributions to run the program with more flexibility.

• Would limit federal standards and requirements on private insurance and Medicaid coverage.

• Favors reducing the amount of money the federal government spends on Medicaid.

“My view is get the federal government out of Medicaid, get it out of health care. Return it to the states.” – Romney, South Carolina GOP Primary Debate, Jan. 20, 2012.

On Abortion/Contraception Issues, Romney:

• Campaigned for governor on a promise to not change existing abortion laws, neither making them stricter, nor more lenient. In 2005, he vetoed a bill expanding access to contraceptives on these grounds.

• Maintains that Roe v. Wade should be overturned by the Supreme Court so that the abortion issue can be decided by states, but also says that until that happens, Roe v. Wade should be considered the law of the land.

• Wants to implement abstinence awareness programs in schools.

• Outspoken against the 2010 health law’s requirement for employers’ health plans to cover contraception without a copayment.

• Opposes federal funding for Planned Parenthood.

Romney’s Reaction To Supreme Court Health Law Decision:

• In a statement after the court’s decision was announced he said that “Obamacare was bad law yesterday, it’s bad law today.”

• Agreed, during an interview with CBS News, with the Supreme Court that the individual mandate is a tax.

Deep Reads:

The Daily Beast:  The Answer Is Unleashing Markets, Not Government
Our divide is fundamental: Republicans believe health care can be best guided by consumers, physicians and markets; Democrats believe government would do better. Some Democrats would have government buy health care for us; set the rates for doctors, hospitals and medicines; and decide what medical treatment we would be entitled to receive for each illness. If you liked the HMOs of the ’80s, you’d love government-run health care…But government can’t match consumers and markets when it comes to lowering cost, improving quality and boosting productivity…The right answer for health care is to apply more market force, not less (Mitt Romney, 05/01/09).

Boston Globe:  Preston’s Blueprint
Long before Mitt Romney unveiled his ambitious plan to provide health insurance to everyone in Massachusetts, he hired Ron Preston — “the best health and human services secretary in the nation,” as the governor once called him – to work on a plan to do in the Commonwealth what no other state has been able to do. Romney took the wraps off his vision in November 2004, and Preston, apparently no longer the best health and human services secretary in the nation, was nudged out by the next May.  Preston and a tight group from inside and outside the administration spent six months answering Romney’s basic question: Could it be done? Their answer: Yes, Massachusetts could insure all its residents. But how the Preston working group planned to do it differed, in critical aspects, from what Romney eventually proposed (Bailey, 1/11/06). 

FactCheck.org: ‘Romneycare’ Facts And Falsehoods
As the 2012 presidential campaign gets under way in just a few months (believe it or not), we expect to see an increasing number of attacks on so-called “RomneyCare.” So as part primer and part preemptive fact-checking, this article is our attempt to set the record straight (Robertson, 5/25/11). 

Boston Globe: Romney And Health Care: In The Thick Of History
The former governor has faced a fusillade from the right for the plan they call RomneyCare. But a look back at the birth of the Massachusetts law shows why he can’t, and won’t, back away. It was an amazing political feat, and no one’s role was bigger than his (Mooney, 5/30/11).

Boston Globe: ‘RomneyCare’ – A Revolution That Basically Worked
The former governor’s health plan is a policy piñata among his rivals. But a detailed Globe review finds the overhaul has achieved its main goals without devastating state finances. The remaining worry is future costs (Mooney, 6/26/11). 

New York Times: Ted Kennedy Helped Shape Mitt Romney’s Career, And Still Haunts It
When Gov. Mitt Romney signed legislation in April 2006 requiring most Massachusetts residents to have health coverage, Sen. Edward M. Kennedy stood by his side, beaming like a proud father. They were onstage at historic Faneuil Hall in Boston, a setting that had a special resonance for the two (Stolberg, 3/24/12). 

The Real Romney (book): Pride In RomneyCare Shows In Official Portrait
In 2008, for Romney’s official portrait, he had been clear about the image he wanted to convey for posterity. He would be sitting on his desk in front of an American flag, next to symbols of two things he held dear. The first was a photo of his wife, the center of his personal universe. The second was the Massachusetts health care law, represented by an official-looking document with a caduceus–often used as a symbol of the medical profession–embossed in gold on the cover. Romney was deeply proud of the law and felt strongly that it should figure prominently in the portrait, which would hang alongside others dating back to the Colonial era. He wanted to be remembered for that (Kranish and Helman, p. 261-262, 1/17/12).

NPR: Romney On The Health Insurance Mandate
In 2006, as Massachusetts’ governor, he talked about the state’s mandate in decidedly non-ideological terms: “We’re going to say, folks, if you can afford health care, then gosh, you’d better go get it; otherwise, you’re just passing on your expenses to someone else. That’s not Republican; that’s not Democratic; that’s not libertarian; that’s just wrong” (Liasson, 5/25/12).

New York Times: Jonathan Gruber, Health Care’s Mr. Mandate
After Massachusetts, California came calling. So did Connecticut, Delaware, Kansas, Minnesota, Oregon, Wisconsin and Wyoming. They all wanted Jonathan Gruber, a numbers wizard at M.I.T., to help them figure out how to fix their health care systems, just as he had helped Mitt Romney overhaul health insurance when he was the Massachusetts governor. Then came the call in 2008 from President-elect Obama’s transition team, the one that officially turned this stay-at-home economics professor into Mr. Mandate (Rampell, 3/28/12).

Los Angeles Times: Romney’s Health Care Plan May Be More Revolutionary Than Obama’s
As he pushes to “repeal and replace” President Obama’s healthcare law, former Massachusetts Gov. Mitt Romney has turned to proposals that could alter the way hundreds of millions of Americans get their medical insurance. In public, Romney has only sketched the outlines of a plan, and aides have declined to answer questions about the details. But his public statements and interviews with advisors make clear that Romney has embraced a strategy that in crucial ways is more revolutionary — and potentially more disruptive — than the law Obama signed two years ago (Levey, 4/23/12). 

Boston Globe: Mitt Romney’s Plan May Undercut Mass. Law
A proposal by Mitt Romney to curtail Medicaid spending would dramatically undercut the way the Massachusetts health care overhaul law has achieved near universal coverage. Although the specifics of Romney’s plan are not public, his overall intent – to rein in how much Medicaid money Washington sends to the states – would probably cripple the Massachusetts health care law, which was made possible by an expansion of Medicaid funding. If Romney succeeds, the result could have an ironic twist: the governor who ushered in the country’s first universal health plan would, as president, put in place policies that could undermine one of his signature achievements (Jan, 5/4/12).