All of these moves signaled to Republican voters that Romney would be with them when it counted. “I stood at the center of the battlefield,” he would tell a meeting of conservatives not long after leaving office. “On every major social issue, I fought to preserve our traditional values.” That would become Romney’s central defense when he was pressed on his long history of directly contrary views: don’t look at what I said back then; look at what I’ve done as governor. “I know there are some that want to go back . . . and say, ‘Yeah, but look at what you said in ’94,’ ” Romney said. “I said, ‘Well, yeah, but I was governor for four years. Look what I did as governor, and look what I ran on as governor.” On gay rights in particular, it is not that his positions have changed, Romney suggested, but that his audience has. “Now someone will say, ‘Yes, but look what you wrote in 1994 to the Log Cabin Club,’ ” he said. “Well, okay, let’s look at that in the context of who it’s being written to.”
A few months after Romney, in December 2005, surprised absolutely no one by saying he would not seek a second term, he and other Massachusetts political leaders gathered for Boston’s famous St. Patrick’s Day breakfast, where, as the joke went, he was on the menu. The roasts at the annual breakfast frequently had bite, but Salvatore DiMasi’s that morning seemed to have a little extra.
The liberal House speaker, who had often clashed with Romney, presented him with a collection of mock gifts, including a replica of an Academy Award. “For a great job of acting like you really enjoyed being governor of Massachusetts,” DiMasi deadpanned. DiMasi then gave Romney a tiny piece of paper—“a list of all your accomplishments as governor”—and noted that the governor was not accepting a salary from the state. “I guess it’s true what they say,” DiMasi said. “You get what you pay for.” It was caustic stuff, but Romney sat there and took it admirably. When it was his turn, he gave as good as he got.
Their political tussles aside, DiMasi’s sharp barbs captured the depth of resentment felt by many in Massachusetts, whose governors always seemed to be on their way somewhere else. Romney’s repackaging for national office had produced a range of reactions, few of them particularly positive. Some were furious at his reversals on issues that were personally important to them. Others felt his presidential ambitions had clouded his judgment about what was best for Massachusetts. “It’s almost as though he had his eye on higher office very early into his governorship. I think it ended up hurting his performance as governor and the fortunes of the party in general,” said Richard R. Tisei, a former Republican minority leader in the Massachusetts Senate, who later broke with many of his GOP legislative colleagues in endorsing a Romney rival in the 2008 presidential contest.
For many voters, for state lawmakers, for political reformers, for environmentalists, for business leaders, for his former gay supporters, and for countless others, seeing Romney turn so sharply from Massachusetts produced not just disappointment, frustration, or anger. There was a wistfulness, too, a lament about what could have been had Romney fully committed himself to the job voters had given him. The high expectations he had set and his obvious capacities only made the letdown that much harder. “I was intrigued when he became governor, because he was supposed to be a breath of fresh air. He was nonideological, looked at each issue individually, and did not play games,” said one Democratic lawmaker. But, the lawmaker added, “Romney blew in and blew out of here.” A majority of voters in a poll cosponsored by The Boston Globe toward the end of Romney’s term expressed an unfavorable view of him. And when his lieutenant governor, Kerry Healey, ran her own unsuccessful campaign for governor in 2006, she often kept her distance from him.
As public resentment about his national ambitions grew, Romney swatted it away as best he could. How could liberal Massachusetts be expected to understand? The state didn’t matter for Republican presidential candidates, anyway. Yet just when many expected him to disengage completely, Romney did the opposite, displaying a dedication and focus that people around him had never seen. Eager to notch a signature achievement before he left office, he took on a problem many others had tried, and failed, to solve. It was a puzzle he had worked over in his mind for years. No state had ever put all the pieces together. But now, Romney decided, Massachusetts would: every resident would have health care insurance. He’d find a way.
[ Ten ]
Health Care Revolutionary
An achievement like this comes once in a generation.
—MITT ROMNEY ON HIS HEALTH CARE PLAN
It was a sunny October afternoon in 2008, and Mitt and Ann Romney were making a return visit to the Massachusetts State House to meet with the portrait artist Richard Whitney. Together they walked to the third-floor office Romney had once occupied, its broad windows offering expansive views of the Boston Common and bustling downtown. His successor as governor, Democrat Deval Patrick, had arranged for them to use it for a photo shoot. Whitney needed the snapshots to paint Romney’s official portrait, an honor afforded every governor.
Romney had been clear about the image he wanted to convey for posterity. Wearing a blue suit, white shirt, and striped tie—the dress uniform of a businessman—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. “As long as the symbol was there, that was important,” Whitney said. “He wanted to be remembered for that.”
Romney hoped the revolution in health care that he, more than anyone, had driven into law would redound to his benefit as a presidential candidate. Who else on the Republican side had tried to do anything as difficult or ambitious—much less gotten it done? But it wouldn’t be that simple. Relentless attacks would follow from conservatives and rival candidates, with objections to its provisions, scope, and progeny: the reform plan would later serve as a template for the polarizing national universal health care law that President Barack Obama signed in 2010.
The story of how the Massachusetts law was conceived, crafted, negotiated, and passed showcased Romney in all his complexity, illuminating his remarkable skills, stubborn limitations, and ideological flexibility. He displayed a willingness to challenge convention with creativity and confidence, a gift for framing a problem and seeing a solution through, and the courage to disregard some political risks. But while his outsider’s mind-set brought fresh energy to an old puzzle, his aversion to the basics of political engagement—cultivating allies, making personal connections, calling in chits—complicated the nitty-gritty of the negotiations. And, at the end, he showed more concern for his own political ambition than willingness to stand behind a bipartisan compromise. Indeed, his yearning for higher office turned out to be both a spur and a shackle, making him hungry for a deal but ever mindful of how it might play to Republicans around the country.
A push by one state to universalize access to health care—a push led from the right—was a novel idea and a high-stakes gamble, both for Romney politically and for Massachusetts, where health care has long been a dominant industry. The nation was watching. No state had tackled health reform in such sweeping fashion. No leader had ever driven a bargain quite like this. And it all started in a conversation with an old friend.
They had been close ever since Bain Capital had helped finance the early growth of Staples, the office supply superstore. The company’s founder, Thomas Stemberg, had worked with Romney for about sixteen years as Romney sat on the Staples board. Stemberg liked to call him a “doubting Thomas,” on account of his famous caution. This had long been Romney’s habit—pushing, prodding, and firing skeptical questions until the risks of a decision were, if not eliminated, clearly un
derstood. In the Staples boardroom, he was always asking, Does this add up? Are we sure this will work?
Now Romney had been elected governor of Massachusetts, and it was Stemberg’s turn to provide the guidance, as a member of his friend’s transition team. During one informal meeting about Romney’s goals for his new term, Stemberg decided to challenge his old comrade to think big. “We were talking about a bunch of stuff,” Stemberg recalled. “I said, ‘Mitt, if you really want to do a service to the people of Massachusetts, you should find a way of getting health care coverage to them.’ ” The health care status quo made no sense, Stemberg went on. There was a “huge number of people going to the emergency room for care at a cost of three, four, five times what it costs to go to a doctor’s office.” That’s wrong, he told Romney, because they were just passing along the expense of that care to others.
Romney was dubious about the feasibility of universal health care. “It struck me, when Tom suggested it, as being, frankly, impossible,” Romney said. “Getting everybody insured would mean a huge tax increase. . . . I think I dismissed Tom out of hand.” Romney also had other things to worry about, chiefly a looming state budget crisis. He had made some ninety-three promises during the governor’s race, and universal health care was not one of them. “You can find a way,” Stemberg told him.
It has been a familiar pattern in Romney’s life. Presented with a monumental task—running for Senate, taking over the Olympics, launching a campaign for governor—he professes skepticism or outright opposition at first. Then, after a period of reflection—after he convinces himself the numbers just might work—he comes around. So it was with health care. As the months went by, Romney began to think: Maybe Stemberg was right. Maybe this is the time. “I must admit, the ‘Aha’ moment was in our conversations saying, . . . ‘We are already paying for people who don’t have health insurance,’ ” he later said. “Those people are getting treated; they’re getting health care. The state is paying for those people—someone’s paying for those people. If we could get our hands around that resource to help people buy insurance instead, it would be less expensive.”
Over the first two years of his term, Romney’s advisers worked quietly to understand the many complexities of health care, sifting through data, evaluating input from experts, and testing theories, hoping to craft a plan that would expand coverage to nearly everyone in the state without breaking the bank. Some of the concepts they settled on had never been tried before. For a long time, Stemberg did not hear from his friend in the corner office. “The next thing I know, he’s hard at work, actually trying to do it,” Stemberg said. “He called to tell me I gave him the idea.”
Romney first thrust health care to the fore at one of his lowest moments as governor. Just weeks after his handpicked slate of Republican legislative candidates got walloped in the 2004 elections, he issued an unexpected plea for bipartisanship. In an op-ed piece in The Boston Globe, he pointed to previous achievements won through cooperation between his office and the Democratic legislature. “In the same bipartisan fashion,” he wrote, “let’s tackle the issue of healthcare.” The initial response fell somewhere between skepticism and incredulity. “This administration hasn’t been willing to work with anyone,” Christine E. Canavan, a state representative, said at the time. “I just came out of a campaign where the man was trying to make sure I wasn’t here anymore.”
Within two days, though, Romney got a bracing response from an unlikely quarter. Ted Kennedy, the liberal lion who had thwarted Romney’s freshman venture into politics a decade earlier, offered emphatic encouragement. One of the great champions of universal coverage, he saw promise in Romney’s gambit. “We’re basically stalemated [in Washington], so the states are going to have to try to come up with a response,” he said. Romney had provided him an advance copy of the op-ed.
Romney didn’t have a plan fully mapped out yet, but he knew what he didn’t want to do. His first secretary of health and human services, Ronald Preston, had circulated a twenty-nine-page study concluding that near-universal coverage was attainable but would cost more than $2 billion a year, require expanding the Medicaid program, and mean imposing mandates not only on individuals to get coverage but on employers to offer it. To Romney, the employer mandate and Medicaid expansion were nonstarters. So was the huge bottom line. But there was increasing consensus on the Romney team that something had to be done. The U.S. Department of Health and Human Services began to signal ominously that a $385 million annual Medicaid grant the state received to extend coverage to the working poor was in serious jeopardy. That represented more than 5 percent of the state’s Medicaid program, and losing the money would mean covering fewer people, not more. There was a great sense of urgency. “You were talking about causing real harm,” said Christine Ferguson, who was state public health commissioner at the time. “The whole calculus changed.”
So they turned to one of Romney’s trusted sources of inspiration: data. It turned out that the state had a lot of it, and the picture that emerged was surprising. Of the estimated 460,000 Massachusetts residents without insurance, more than a third could afford to pay for basic coverage. Many others were eligible but not currently enrolled in the existing state Medicaid program, whose costs are split with the federal government. That left 36,000 short-term unemployed and about 150,000 who were working but caught in a health care vise—making too much for Medicaid but too little to afford private coverage. Those were the groups that would need subsidies to acquire insurance; universalizing health care boiled down to finding a way to cover them. Viewed this way, the numbers weren’t small, but they weren’t outlandish, either. Suddenly the problem seemed manageable.
The first task was finding a way to get uninsured people who could afford insurance to buy in. Romney’s answer came in part from Jonathan Gruber, an economics professor at MIT and a leading adviser, usually to Democrats, on health care. Gruber had a computer model designed to predict how individuals and businesses would respond to changes in the health care system. What it showed, Gruber said, was that requiring individuals to carry insurance “made enormous sense.” Romney was intrigued, because he believed in the principle of personal responsibility. And if younger, healthier people were coaxed into the system, the cost of premiums would moderate for a larger population. “Romney was like an engineer,” Gruber recalled, “saying, ‘We can actually get to this goal in a financially feasible way. Isn’t that neat?’ . . . He wanted to do what’s right.”
Romney’s political advisers, however, were not keen on his taking on such a vast challenge, so uncertain of success. He was venturing into policy turf long dominated by Democrats. Even though Romney’s approach was fundamentally different in most respects, one close aide privately called the idea Dukakis II, a reference to the failed 1988 effort by then-Governor Michael S. Dukakis to phase in near-universal coverage. “They were making the realpolitik argument, something along the lines that ‘Republicans don’t do that,’ ” Gruber said. But Romney challenged the dissenters. “Romney was arguing with them, saying, ‘No, this is the right thing to do,’ ” Gruber added.
In the late spring of 2005, not long after his meeting with Gruber, Romney gathered with a dozen top policy and political advisers in a conference room near the governor’s suite on the third floor of the statehouse. Romney’s team was finalizing his health care bill, which he would soon file with the legislature. This was a pivotal meeting, and Romney was in CEO mode, presiding over a freewheeling debate to identify the strengths and weaknesses of their bold initiative. On the table was a critical question that would, in many ways, define the plan and also Romney’s political ambitions, wherever they would lead him: should adults with sufficient income be required to buy basic health insurance or pay a penalty? “We discussed the need for people to take responsibility for their health care,” said Amy Lischko, who was the state’s health care policy director. Romney was drawn to that basic moral principle. “Everybody in the room was very aware it was a novel
approach,” recalled Timothy R. Murphy, who was Romney’s point man on health care. “I don’t think it was lost on anyone that Mitt had an emerging national profile, but there weren’t many of us thinking there would be a national debate on this.” Instead they were focused on what would both work in Massachusetts and fit the demands and philosophy of the man at the head of the table. “We felt that personal responsibility was consistent with what the governor stood for,” Murphy said.
If Romney’s policy team was on board, his political brain trust remained skeptical, believing the hazards spoke louder than the policy-making opportunity. By mid-2005, it was already expected within Romney’s administration that he would serve only one term and seek the 2008 Republican presidential nomination. Moving hard on health care would put Romney way out front in a cause generally identified with the Left—even though the individual mandate was a concept with long conservative and Republican roots. In the early 1990s, the Heritage Foundation, a conservative think tank, endorsed the idea and some Republicans offered it as an alternative during debate on the doomed national health care push by then–first lady Hillary Rodham Clinton. One of the early GOP advocates for an individual mandate was then-senator John Chafee of Rhode Island, whose plan Romney had voiced support for during his race against Kennedy.
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