Over the final weeks of the campaign, CJR has been publishing a series of pieces under the headline “Ask Obama This” and “Ask Romney This,” suggesting themes and questions that reporters and pundits can consider posing to the presidential candidates. There’s not much time left for that, of course, but the questions this series raises will be around for the winner to deal with. This installment focuses on Mitt Romney and his plans for American healthcare.

Okay Governor Romney, we know you don’t like Obamacare—the mandate that people must carry insurance, the government subsidies to help people buy the required coverage, and the expansion of Medicaid to help poor people get coverage. You have been murkier about other parts—ending insurance denials for people with pre-existing conditions, and letting young adults stay on their parents’ policies until age 26. Yet many of these ideas were adopted in the state where you were governor, as you know, and they have given Massachusetts the grand prize for the state with the most people covered—96.6 percent according to the latest Census numbers.

So the question is, What will you do as president to achieve those kinds of stats and cover nearly 49 million Americans who are without insurance?

Your website is sketchy on details, but there have been some clues on the campaign trail. And then there was the first debate with the president, during which you told us :

Preexisting conditions are covered under my plan. Young people are able to stay on their family plan. That’s already offered in the private marketplace. You don’t have to have the government mandate that for that to occur.

That statement deserves careful examination, and NPR began to do that last week. First, it’s important to let folks know that your staff walked back some of those claims. No, your spokesperson said, insurance companies would still be able to deny coverage to people with preexisting conditions who have not maintained continuous insurance coverage—that is, they have not obtained new individual insurance within 63 days of losing group coverage.

What you seem to be describing is the old HIPAA (for Health Insurance Portability and Accountability Act) law, passed in the mid 1990s—a Band-Aid that Congress slapped on a bleeding wound—no insurance coverage for too many Americans. At the time, I wrote in CJR , HIPAA “was the perfect symbolic law giving the impression of solving a problem without doing much.” If this is what you have in mind, then it likely that millions who have health problems will still have trouble obtaining insurance. So the question remains: What will you do for them?

You say young people are already able to stay on their parents’ insurance plan and the private market has done the job. NPR reported that you would offer no guarantee that insurance companies had to cover young adults, although some carriers have voluntarily agreed to that. A few weeks after the president signed the
Affordable Care Act, three insurance biggies—United Healthcare, WellPoint, and Humana—decided to let young adults stay on their parents’ insurance. A goodwill gesture, one might say. Presumably those companies, and maybe some others, would continue to do that if you repeal Obamacare. But without a law holding them to it, what’s the guarantee they will—especially if it turns out these young adults boost insurance premiums? During the debate on Obamacare, spokespeople for the insurance industry repeatedly claimed that giving insurance to young adults would simply cost too much and make premiums go up.

Governor, your other point about letting the states do the job of covering their residents also deserves scrutiny. During that first debate, you said, “the best course for healthcare is to do what we did in my state: craft a plan at the state level that fits the needs of the state.” Many states have been there, done that. Tennessee comes to mind. It’s TennCare program, also called a model for the country at the time, expanded coverage to people with pre-existing conditions and to those who couldn’t afford coverage. But it ultimately failed, after ten years, because of lack of cost controls.

Even in your Massachusetts, the jury is still out on whether the cost containment measures the state recently enacted will do the trick and keep the law viable for the long haul. Furthermore, these examples raise the question of whether states are really the ideal vehicles—or have the clout—to control costs and curb what providers can charge for medical services in what is really becoming a national system. Of course, the jury is out on the cost control measures in Obamacare, too.

You call for letting consumers buy insurance across state lines. Presumably that means if shoppers in Ohio don’t like the insurance selection in the Buckeye state and wanted to see what Indiana had to offer, they could ring up a carrier in Indianapolis and ask for a quote. The idea is they would shop for the lowest price and somehow the magic of the marketplace would make insurance cost less. Here, it seems important to remind you that it’s the doctors and hospitals that ultimately set the price of care, not the insurance companies.

Also, crossing state lines seems to open a regulatory free-for-all, and throws into question the role of the states in protecting healthcare consumers. Meanwhile, we have seen a great deal of consolidation in hospital systems, giving them market power to dictate price. It’s fair to note that big concentrations of economic power don’t necessarily mean lower costs. In fact, it could mean just the opposite, as The National Journal has shown.

One last point about states crafting their own plans: Your website advises that you want to “ensure flexibility to help the chronically ill,” and that effort includes high-risk pools for people with preexisting conditions. This is not a new idea. For several decades, states have offered high-risk pools for people who were uninsurable in the private insurance market—you know, the ones that Obamacare targeted for help. By any measure, they haven’t worked. Premiums are too high for most people, coverage too skimpy, and waiting periods before coverage kicks in too long.

In fact, when Congress passed Obamacare, it stuck a provision in the law that gave the states extra money to set up a sort of super high-risk pool to help people until 2014, when insurers are required to take all comers—s sort of a stopgap measure. These pools have not been successful either, and you don’t hear even the president talk about them on the stump. Federal officials estimated that 375,000 people would enroll by the end of 2010. But as of September of this year, less than 78,000 have. This effort, too, was plagued by the same deficiencies—high cost, for example. Yet you seem to say this “solution” is still a viable one.

So there you have it—even at this point in a long campaign, lots of questions and few answers about what you will do to replace Obamacare.

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The Lowdown on High-Risk Pools

Climbing Medicaid Mountain




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Trudy Lieberman is a fellow at the Center for Advancing Health and a longtime contributing editor to the Columbia Journalism Review. She is the lead writer for The Second Opinion, CJR’s healthcare desk, which is part of our United States Project on the coverage of politics and policy. Follow her on Twitter @Trudy_Lieberman.