“We’re spending a billion dollars giving health care to people who don’t have insurance. And my question was: Could we take that billion dollars and help the poor purchase insurance? Let them pay what they can afford. We’ll subsidize what they can’t.”

That was Massachusetts Governor Mitt Romney in 2006, on the passage of the state’s healthcare reform bill, the most ambitious effort by any state to date in extending healthcare coverage to its entire population and, famously, the model for the federal reform passed in 2010 under President Obama.

Six years later, Romney is haunted by his healthcare legacy as he seeks the presidency. Meanwhile, his successor, Democrat Deval Patrick, is undertaking his own equally ambitious healthcare agenda by aiming to curb rising costs. As both the presidential campaign and the latest Massachusetts reform efforts garner media attention, it’s worth looking back at the history of so-called “Romneycare” to learn a bit more about a presidential candidate as well as to understand why the Commonwealth remains at the forefront of health policy innovation.

A Uniquely Massachusetts Effort

It is no accident that the nation’s healthcare reform bill ended up based on Massachusetts. As the Pioneer Institute, a Mass.-based free market think tank, writes in a paper on the state’s 2006 reform, “Massachusetts has long held a reputation for innovation and creativity in healthcare policy.”

That is the result of the state’s deep expertise in medicine, as well as the political heft of the healthcare industry.

As an SEIU brief on the state’s 2006 reform notes, “Massachusetts’ provider system and insurance system is almost completely not-for-profit, held in high regard, and the major economic engine of the Massachusetts economy.”

And it was in large part the clout of that engine that put Romneycare into motion.

Blue Cross Blue Shield and Partners Healthcare, who together accounted for more of half of the state’s insured population, undertook the “Roadmap to Coverage” project to research the expansion of health insurance in the state and provide recommendations. Meanwhile the ACT!! Coalition brought healthcare providers together with unions and activists to push reform. Finally, the federal government was keen on renegotiating the state’s $385 million block grant for Medicaid and was pushing for expanded health insurance coverage.

Romney’s Leadership

While it may be tempting for Republicans to assume that Romney was merely pulled along by a Democratic legislature and an industry bent on reform, that simply is not true. In 2006, Romney claimed that upon taking office a business executive had urged him to take up universal coverage, to which he replied “I don’t want to raise taxes and I don’t want to have a universal coverage like Hillary-care,” referring to a single-payer, government run insurance program. “So I don’t know that it’s possible.”

Nonetheless, in 2004 Romney the problem-solver created a team to explore healthcare reform options that would be ideologically palatable. What his team came back with was a plan more ambitious even than what the state Senate’s Democratic leadership had been considering.

Whereas Senate President Robert Travaglini initially proposed a plan to cut the uninsured population (then between 7-8% of the state) in half, Romney’s proposal aimed for universal coverage. But it did so in a way that by and large left the private insurance system in tact.

“There really wasn’t Republican or Democrat in this,” said Romney in 2006. “People ask me if this is conservative or liberal, and my answer is yes. It’s liberal in the sense that we’re getting our citizens health insurance. It’s conservative in that we’re not getting a government takeover.”

A Conservative Plan

It seems strange now that Romney would stand alongside Senator Edward Kennedy, sign into law a bill mandating universal healthcare coverage, and tout his conservative bona fides. But in a pre-Obamacare world, there was nothing strange about it.

In developing his proposal, Romney leaned on a plan outlined by the ultra-conservative Heritage Foundation, a Washington think tank. Central to it was the now well known “individual mandate,” a requirement that everyone in the state have health insurance or else face financial penalties. Households with income below 300% of the federal poverty level would receive subsidies towards the purchase of insurance.

To that, the legislation added new requirements for employer participation in providing or otherwise helping to subsidize health insurance, various transparency provisions, and the establishment of “the Connector,” a quasi-public authority to manage the insurance market for individuals and small businesses.

“Special thanks as well to the Heritage Foundation,” said Romney on the day the bill was signed. “Two of its leading scholars are the ones who helped design and craft what we now call the Connector, which is the centerpiece of the insurance reform portion.”

Don’t Look Back

Fast forward to 2012. Romneycare has achieved what it set out to, with more than 98% of the population insured and health outcomes improving. Though costs remain a challenge, as evidenced by Patrick’s current focus, the 2006 effort was explicitly based on a coverage first, cost second approach.

Meanwhile, Romney wants to talk about anything but his healthcare record. For a while he cited Massachusetts as a model for national reform, but today he says that every state should be free to do their own thing.

It’s hard not to see the reflection of the Tea Party in Romney’s pronouncements on the issue and given his record as Governor, it doesn’t feel right. Everything about Romney’s business and academic history suggests that he is a problem-solver above all else, and that is apparent in his healthcare legacy. He had certain conservative principles in mind when he came into office, but didn’t let them get in the way of finding a solution to the challenge of extending health insurance – a very real quality of life issue – to the Massachusetts population.

Today, the Commonwealth remains engaged in solving the most pressing health policy problems facing not only the state but the nation. Sadly, Romney the pragmatist is nowhere to be found.

Image via ThinkProgress