As John Hood notes below, Mitt Romney’s new health care plan is quite different in some crucial respects from the plan he pursued in Massachusetts. But the reason given by the Romney team (that “he would have greater powers in the White House” than he did as governor) strikes me as not quite right. In fact, it misses an opportunity to make an important point about federalism—both in general and in connection with health care in particular.
The states and the federal government have different kinds of responsibilities, and properly address themselves to different aspects of national problems, like the cost of health care or access to insurance. If your goal is to address the problem without unduly constraining the freedom of families to make their own decisions, and without drastically undercutting the efficiency and quality of care, it makes sense to deal with much of the challenge of health care reform at the state level, and to use the levers of federal power to make that possible (mostly by removing obstacles and eliminating problems that result from current federal policies) rather than to commandeer all health care regulation to Washington. Each state has different strengths and weaknesses, and in many cases also different kinds of health care problems, and our system (in which insurance regulation is mostly the purview of state governments) actually offers effective ways to make the most of that fact. (Jim Capretta and I made this case in the Weekly Standard last year).
Conservatives have not always been enthusiastic about health care federalism because they want to enable Americans to buy insurance across state lines, and so to avoid benefit mandates that make insurance extremely expensive in some states. But reforms of the federal tax code, greater freedom to use Medicaid funds to help the uninsured, and state-by-state reform of the particulars may well offer a more powerful route to effective (and free market) health care reform—and of course, a Democratic congress isn’t about to allow the purchase of insurance across state lines anyway.
The most important element of the Massachusetts reform was not its coverage mandates, but the creation of an insurance marketplace (called “the connector”) that allows individuals and small businesses to get the same tax treatment as big companies, and makes coverage much more portable as people change jobs. These are crucially important reforms that speak to the concerns of middle class families while enabling more effective assistance to the uninsured, and the kind of Federalism Romney now has in mind (which is much like what Giuliani has proposed, and what the Bush Administration has pursued) would make it easier to do that elsewhere. It’s a lot smarter than trying for a national version of the Massachusetts plan. But it means that in some crucial ways the president actually has less, not more, power over health care than a governor. And that is as it should be.