Romney's contortions on health care

Editor's note: Dr. Aaron E. Carroll is an associate professor of pediatrics at the Indiana University School of Medicine and the director of the university's Center for Health Policy and Professionalism Research. He blogs about health policy at The Incidental Economist.

(CNN) -- In 2006, Gov. Mitt Romney signed Massachusetts' answer to health care reform. It provided free insurance to everyone who earned up to 150 percent of the federal poverty line.

It set up the Commonwealth Health Insurance Connector Authority, an "exchange" where individuals could shop for insurance that met regulatory standards.

It also subsidized the cost of insurance, on a sliding scale, for individuals making up to 300 percent of the federal poverty line. Finally, to prevent free riders and encourage "personal responsibility," it included both an employer and individual mandate.

If all this sounds familiar, it should. With a few small changes, I could have easily been describing the more recently passed reform signed by President Barack Obama. That law, the Patient Protection and Affordable Care Act, has more subsidies, some cost controls Massachusetts lacks, and some additional taxes and spending cuts, but otherwise is very similar to the Romney plan. In fact, some of the same experts were involved in designing both.

Unfortunately, an approach to health care reform once seen as full of "good conservative ideas" has now become, to many, an unacceptable affront to liberty. Romney, once praised for his state-based health care reform, is in political peril because of it.

Last week, he spoke on health care in Ann Arbor, Michigan. It was not an easy speech to give.

He spent the first part of his speech defending his accomplishments in Massachusetts. He defended the need for reform and the need for the individual mandate. He did such a good job that some said the White House should have taken notes.

Romney also sought to show how Massachusetts' plan differed from Washington's. Here, things were less clear. He was correct that Massachusetts did not alter Medicare, but since Medicare is a federal program, that's not surprising. He was also correct that his plan did not involve significant new taxes, but it did involve some, and it also benefited from a large amount of federal aid.

Romney then talked about federalism. He is correct that his reform was state-based, and the federal law is not. So it's reasonable to suppose that Massachusetts' individual mandate could be constitutional while the federal mandate is not. But let's say the courts uphold the federal mandate, or that somehow the mandate is stripped from the bill. Would Romney support the federal law then? That seems unlikely.

That leaves us with Romney's assertion that his reform was a state-based solution to a local problem, and that perhaps it's not a federal answer to a national problem. But why? What is it about the needs of the uninsured in Massachusetts that it is so different from Texas or Florida? To believe this "local" argument, that needs to be explained.

Moreover, I'd be curious to see if Romney would defend recent actions in Vermont as that state moves toward a single-payer system. Is that the kind of experimenting he'd support? I ask, because that's the kind of experimenting the PPACA already likely allows.

The final part of Romney's speech concerned his plans for how he might replace the federal law. Romney wants to empower states to become laboratories for health care reform. It's ironic, because his best example for this is Massachusetts. Regardless, he would support block grants for Medicaid and decreased federal regulations in order for states to cover the uninsured as they see fit.

Just a few slides later, however, Romney supported the idea that people should be allowed to purchase insurance across state lines. Both this and the federalism argument are conservative approaches to health care, but rarely at the same time. That's because allowing people to buy insurance out of state allows them to avoid state regulations, limiting a state's ability to innovate or control its own insurance market.

Romney also praised tort reform, often held up as a means to control costs. While malpractice reform may be warranted, capping punitive damages will likely do little to change physician behavior, end the practice of defensive medicine, or result in significant spending reductions.

Romney seeks to increase the use of Health Savings Accounts and increase market forces in health care. This isn't new, but there's a fair amount of evidence that these kinds of approaches do a better job of making insurance cheaper for healthy people rather than helping care get where it's needed.

Finally, like many before him, Romney wants to provide tax subsidies to individuals who buy insurance to give them parity with those who get it from their jobs. This is a fine idea, but expensive. I have no idea how it would be paid for without the taxes or spending cuts that Romney seems to dislike.

It's too bad that the man who once achieved a remarkable bipartisan reform in Massachusetts must now run away from it.

As governor, Romney once surveyed the landscape and sought the most conservative approach to health care reform he thought he could achieve. It's ironic, and dispiriting, that he must now act as if that option isn't available.

The opinions expressed in this commentary are solely those of Aaron Carroll.