I miss those days when politicians wanted to work together for the good of their constituents. I always admired Romney and this article reminded me why.
I've just gone beyond reading the post to watching the video of the Romney interview as well. It was a great interview. (Perhaps Bulwark will let go of its IP rights on it, and release it on YouTube.)
1) I find a major misrepresentation or misunderstanding from Romney in it, though.
Based on this fact: For a person showing up at an emergency room, regardless of insurance status, the emergency room (due to the Reagen-era EMTALA law)
a) has the legal obligation to stabilize them only,
b) and the person is legally responsible for the bills afterwards.
(Digression on info source: I have been able to verify this easily from reliable sources via search engines when I double checked the info months and years ago, though today google changes seem to be making it a tougher job, with the google AI getting confused by less-reliable Reddit posts and such, that I don't deem reliable enough.
"EMTALA requires hospitals that offer emergency services and accept Medicare, to screen and then stabilize a patient with an emergency medical condition—regardless of a patient’s ability to pay.
EMTALA, does not, however, require hospitals to cure underlying medical conditions (e.g., cancer) or provide outpatient care (e.g., chemotherapy).
EMTALA is also not a substitute for health insurance. After treating a patient under EMTALA, a hospital may still bill the patient for services that they received.
Before EMTALA became law in 1986, hospitals had no federal requirement to treat uninsured patients."
I point out that much of what is turning up in my search attempts on the matter of patients being billed for EMTALA-required services is getting me to posts from our government, like at CMS, pointing out the emergency services that they have to give you at the E.R. and all of the rights you have, but seemingly taking pains to avoid saying that you are legally responsible for the bills for those emergency services. Could it be the new administration that is responsible for that?
End digression on info source.)
--
Anyway, Romney's indication that pre-Romneycare, a person with a $100,000 a year income could just not have insurance and show up at the ER and everything would be O.K. seems quite inaccurate. They could be made to pay the bills afterwards, and, as well, non-emergency care, say chemotherapy for cancer, was not part of the required ER care.
I do understand that a person might have local knowledge that a certain hospital might not bill, finding the money not worth recovering as there was not much to recover in most cases, or as an ethical decision, but this is certainly not guaranteed. It would seem to be a genuinely bad decision not to carry health insurance with an income of $100,000 a year, and presumably some savings to lose.
(I suspect Romney may know this. He is a politician. Politicians have to do the valuable work of convincing the people, who are often both silly and stupid, so I suspect he is oversimplifying and distorting intentionally.)
Yes, people at very low incomes, and with little in assets to lose, may have done OK with just EMTALA service, and whatever supplementary care they could get provided by charitable organizations, but not the higher income people.
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2) I do not know for sure, but I suspect that with Romneycare, a certain lower income group may have had coverage that was estate recoverable. Thus, whatever 98% coverage rate in Massachusetts, or whatever was said was the rate with Romneycare in the interview, the rate was possibly incorrect in that maybe 6% of the people had an estate recoverable loan, until death, for whatever medical expenses occurred, and not any kind of insurance.
I was living in Massachusetts for 4 years of Romneycare, so I should know about whether that was the case, but I am afraid I do not. (Perhaps someone else does know an can reply.)
My suspicion of during Romneycare is because I do know that from the initial ACA going into effect in Massachusetts in 2014, until sometime in 2024, about 6% of the people in Massachusetts, those 55 and older who had ACA expanded Medicaid as coverage, had one of those loans until death for whatever medical expenses occurred, though it may actually have been real insurance, with a loan until death for the premium, for some of them. (I couldn't figure out myself which of those two it was, and I think it may have varied based on exactly how your particular expanded Medicaid program happened to be funded.)
That is because of the Massachusetts decision to estate recover ACA expanded Medicaid, from 2014 to mid 2024, under its Medicaid estate recovery rules.
(I have complained about that, and the recovery still affecting ACA expanded Medicaid in some other states, within this earlier-today comment:
I feel that the mainstream news sources, disappointingly including the New York Times, do a miserable job of pointing out critical details (possibly due only to being under-resourced).
I feel that those details would benefit a portion of their readers who seek and would understand them. Thus, I continue my habit of plopping down details I have picked up from the tiny substack wonkosphere here on Jonathan Cohn, where they might be of use to some.
In this case, I am plopping down on the effects of the lapsed ACA expanded subsidies, which lapsed 1/1/26 at the insistence of the Republicans.
Based on the initially-available data, including just what happened through the end of Open Enrollment in January, these are the findings:
OPEN-ENROLLMENT RESTRICTED, NOT SPLITTING BY INCOME GROUP
About 4.9% of the 24 million people did not re-enroll. This is across all income groups considered together, and not splitting people down by income.
This available-now open-enrollment-only data has limitations that make it tend to overstate the number keeping coverage, especially because about half of the people considered re-enrolled were automatically re-enrolled, and are expected to not actually follow through and pay for coverage. Additional others are expected to drop coverage later this year or eventually, finding the premiums work out now to be too high to successfully manage.
OPEN-ENROLLMENT RESTRICTED, RESTRICTING TO OVER THE RETURNED 400% FPL SUBSIDY CLIFF
This zone of income is of special interest to me, because it's where the really humongo cost increases arise.
Thus, below 400% of FPL, people would have experienced a rise in the net premium they have to pay of up to 2% to 4.5% of their income, which would be for the same plan as without the lapsed expanded subsidies. (Many of those might have been able to bring down the increase in what they have pay by choosing a cheaper plan, which, as we know from previously mentioned data details, did actually happen.)
Above 400% of FPL, where subsidies stopped entirely with the lapse of the expanded subsidies, it is not hard to find increases of 40% of income on the net premium, with, thrown in, a jump from a mid-level plan down to the cheapest available plan in that case. Thus, in Wyoming, a 62 year old couple with an income of $88,000 a year has premium jump from about $6,000 a year to about $40,000 a year, going mid-range to cheapest available, as well.
In some other states, it's not 40% of income. Older people might still have 25% of income jumps, and in younger ones, closer to 30, it might be 5% to 20% of income. (Very roughly--I have not researched this precisely.)
Thus, one expects people over the returned 400% of FPL "subsidy cliff" might have really been thrown under the bus here, and both my look at the data:
show that, with similar numbers, though some of the exact computations we went after differ a little bit.
Thus, overall, we have numbers like around 38% of people in the just-over-the-cliff 400% to 500% of FPL group dropping out of being covered from 2025 to 2026, with it being even more of
a serious drop in some of the highest-premium states, like WV and WY.
However, with these complexities:
Charles and I both observed about 250,000 to 300,000 people seem to have moved themselves into the just below-the-cliff 300% to 400% of FPL income group on the exchange since 2025. Obviously, those people have either decided to work less and make less money, saving that humongo premium jump over-the-cliff, or work the same but keep profits in a corporation that they own that employs them--keeping the money outside of ACA-subsidy use. O, they were just putting in a false low number as estimated 2026 income on the exchange. (In the latter case, they will have to pay back all of the savings at tax filing time for 2026, which ends a year from today! Those are the rules, and those people will not be pleased!)
Anyway, where I or Charles has found say that 38% dropping, it is expected that some of the people in the 38% actually didn't drop, but took the work-less or try-cheating approach.
There is another slight complexity coming from that a proportion of people who appear as missing from 400% to 500% FPL group in 2026, say that 38% again, may have gotten omitted because, seeing they were not going to get a subsidy, they avoided entering an income on the exchange. (This not entering an income, if they kept coverage, would tally them as covered in 2026, but in a different group, the "unknown income" group, rather than the 400% to 500% FPL group in the released data from CMS. ) I tend to believe this number moving to unreported income because no subsidy now is small, because, all through open-enrollment, there was the possibility of a partial removal of the 400% FPL subsidy cliff in legislation that even a few Republicans in Congress were supporting. (So, entering an income would be the way to make that possible much lower premium possible automatically, without lots of work later.)
Being very conservative, though, I did a pooling method of all the over the cliff income groups with the no-income-reported group, and still found about a 16% coverage drop in that combined group. (It's a certain group, probably of mostly over the cliff people, dropping at an 16% rate. Still much higher than the overall 4.9% dropping rate. )
My intention is, eventually, to make, and post, a table where you can kind of see, in all of these over the cliff cases, how many actually dropped coverage, how many may have just lowered their income to below the cliff, with it also clear in my table which numbers are subject to possible smallish overestimates of proportion dropping from people to switching to not reporting an income on the exchange.)
BEYOND OPEN ENROLLMENT:
As time goes on, there is the expectation that many more people will drop than shown in the prior numbers from just open enrollment. Many, indeed, were auto-re-enrolled, and may never pay the premium.
Such numbers, being released at the Federal Level, are at least many months away. I am also not sure those numbers will include by-income numbers, allowing us to isolate the over-the-cliff cases.
Charles Gaba is always looking for early data, from single states with their own exchange, where we get an earlier idea.
He already has one post on Colorado, https://charlesgaba.substack.com/p/colorado-q1-effectuated-enrollment , where already he has a 5.1% higher drop rate than at the same time last year. (Further, Colorado has some partial state-financed mitigations of the subsidy increases, so it would be a state that tends to understate the eventual coverage losses across all states, most of which did not mitigate at all.)
Could you discuss how the voting system contributes to the mess? Consider two alternative ways to oppose the Democratic approach to nationalizing Romneycare: one would be to have an alternative approach drafted, cooperate with the Democratic approach, wait for flaws to become apparent in that Democratic approach, and present your alternative as a fix. The other is to do everything to sabotage the Democratic approach.
Democratic voters would universally prefer the first approach over the second. However, the current voting system would give any Republican embracing that approach zero credit for being the preferred Republican among Democratic voters. Instead, the only question that matters for any Republican politician's interests is what do the majority of highly engaged Republican voters want. With a clear majority of that group favoring the second approach, elected Republican fall in lockstep behind the approach of sabotage and display imperviousness to evidence that the Democratic approach has any merit.
All that is needed to get Republican pols to play a constructive role is a voting system that rewards the candidate who induces the most voters to say, "I'd rather a Democrat get elected, but if Republican is going to be elected, I want it to be that one."
I am pleased that Mr. Romney and Mr. Cohn covered the partisanship problem, but I noted they missed the blatant lying and deception on the Republican end, that I've particularly noted myself since a bit before the end-of-2025 government shutdown.
1)We have the overwhelmingly false Republican assertion that the Democrats were shutting the government down in order to provide healthcare to undocumented immigrants, which was made not just by POTUS, but also by:
"it is a fact, that no one can dispute, that they [the Democrats] shut the government down over restoring free healthcare to illegal aliens as part of their $1.5 trillion wild partisan wish list."
1c) For anyone interested, I have a transcript of exactly what Vance said, videos of POTUS making the assertions, and analysis where I discuss the slight element of truth in some of the assertions, based on that 1% of the money involved in the matters that the government was shut down over was for undocumented immigrants (ER care--legally required by the Reagan-era EMTALA law), perhaps an additional 7% was for "legally present" people, who are not undocumented, but who the Republicans prefer to think of as undocumented). Here:
2) Republicans John Thune and Mike Johnson both used a graph, labelled "Obamacare Plan Premiums Have Increased Nearly 2x Faster Than Employer-Based Plan Premiums since 2014", to justify not extending the ACA expanded subsidies.
However, I'm pretty sure that graph is erroneous, owing to an omission of a major component of the cost from the ACA plans that existed between 2014 and 2017 only. As well as a different large error. When I tried, myself, to counter the errors, I got the ACA plan premiums rising either just a little more, or possibly even a little less, than the employer premiums.
3) On a matter that only the wonky tend to follow (Cost-Sharing-Reduction financing and "silver loading"), a Republican lawsuit early in the ACA to try to weaken it succeeded, but actually wound up backfiring, and making the ACA coverage somewhat stronger.
Recently, Republicans have been trying to undo their mistake with legislation to undo the inadvertent strengthening.
However, Charles Gaba caught Dr. Oz, head of CMS himself, representing that the thing the Republicans are doing, has exactly the OPPOSITE effect--a strengthening of coverage--than the true effect--a weakening of coverage.
I also caught that opposite-of-actual-effect representation earlier, myself, in the specifications of the Crapo-Cassidy Senate bill.
"2) Republicans John Thune and Mike Johnson both used a graph, labelled "Obamacare Plan Premiums Have Increased Nearly 2x Faster Than Employer-Based Plan Premiums since 2014", to justify not extending the ACA expanded subsidies.
However, I'm pretty sure that graph is erroneous, owing to an omission of a major component of the cost from the ACA plans that existed between 2014 and 2017 only. As well as a different large error. When I tried, myself, to counter the errors, I got the ACA plan premiums rising either just a little more, or possibly even a little less, than the employer premiums."
>>> " Romney made clear he thinks Democrats deserve plenty of blame for the degradation of politics—because, he said, they took actions (like using executive orders to wipe out student loans) that violated constitutional norms and staked out positions on cultural issues (like transgender athletes) that he believes made more Americans sympathetic to MAGA."
Mitt. You get points for doing the right thing, but I deduct points for hedging with this dumb bullshit. Christ's sake
I have lived in Massachusetts for about 16 years now, and in fact moved here in part because, where I was previously, upstate New York, the system they had there: pure, non-age-based community rating, without a mandate to carry coverage, was starting to experience one of those adverse-selection-based death spirals, with the cheapest plan available to me, or any one person of any age in that area, set to rise from $800 a month to $1200 a month, in a period of over less than 3 years.
Romneycare, in effect here at the time, offered me coverage for about $700 a month (without a subsidy--I declined the available subsidy).
Some notes:
1) Massachusetts still has its mandate from back in the Romneycare days. (When the ACA had a mandate, there was both a state mandate and the federal mandate.)
2) The state mandate, like the original, removed federal mandate, is probably inadequate to completely cut down the higher-price effect from significant adverse selection. Massachusetts controls the problem in a way which not many, or perhaps any, other states do. It requires actuarial pooling of small-business plans with ACA plans. (Thus, the small-businesses have much less adverse-selection, and dilute the adverse selection. Everything is a trade-off, of course. Small businesses wind up a bit worse off than they would otherwise be.)
2b) With the loss of the expanded subsidies, and the return of the 400% of FPL "subsidy cliff", the pooling of small businesses and ACA plans doesn't solve the affordability problem.
"I have friends who are 60-year-olds in Massachusetts like me. I have a friend who’s going from paying $8,000 a year to $25,000 a year for health insurance. I don’t know what his income is, but even if your income was $100,000, that’s 25% of your income. That’s a lot of money. That’s unaffordable."
3) Let us not idealize the world, or Massachusetts, or the people and government of Massachusetts. The ACA had some pretty-good-sized problems as administered in Massachussetts, and probably still has some, from Massachusetts' imperfect handling of things. I have two in mind:
3a) Massachusetts was one of several Democratic-governed states that had a Medicaid estate recovery policy that would estate-recover from ACA expanded Medicaid recipients who were 55 or over when they had the expanded Medicaid. It was unclear, as far as I could tell, whether the state would go after an annual fixed capitation payment, or all medical bills paid out, from the estates of people who had the recovered expanded Medicaid. If it was the latter, then the person with that ACA expanded Medicaid had no health insurance at all. They had, precisely, a loan, until death, for whatever medical expenses occurred.
This was fixed, finally, in the middle of 2024 (over 10 years later than the ACA provisions started, and even later if something like it applied to Romneycare). It was fixed due to the impetus from two state legislators: Comerford and Barber.
(Before 2024, Massachusetts was boasting something like a 98% "health insured" rate, the highest in the country. I used to go around trying to correct that with that only 92% were insured. 2% were uninsured, and 6% had either a loan until death for whatever medical expenses occurred, or insurance, with a loan until death for the premium.)
Last I heard, though Massachusetts did fix this problem in 2024, Democratic NJ and MD still have the recovery problem.
(For those interested, I have details on the Medicaid estate recovery thing, as it affects ACA expanded Medicaid, on my post here:
3b) In my roughly 8 years using the ACA in Massachusetts, I also caught an apparently unstoppable tendency of the state to reclassify people from expanded Medicaid (income below 138% FPL) to subsidized on exchange (income above 138% FPL), or in the reverse direction, absolutely as soon as they detected an income change crossing the threshold. Up to, I don't know how many times a year. Changing provider network each time!
(With the ACA being a complex part of our byzantinely-complex health insurance system, and with each of 51 states + D.C. having their own expanded Medicaid eligibility system, and many having their own ACA exchange, undoubtedly all kinds of states have similar custom problem sets afflicting their populations. I have noted here:
and elsewhere, that the new more-frequent (at least twice a year) eligibility checks for expanded Medicaid, as well as the work requirements, will expand the miseries of people, as the 51 states tackle the new requirements in their own, customized way. (The excess thrashing up and down between expanded Medicaid and on exchange that I reported in Massachusetts is now forced on all states by the twice-a-year expanded Medicaid eligibility evaluations.)
This article was equivocal about whether people are healthier because of Romneycare. On the most basic measure of health and wellbeing—life expectancy—MA is #2 in the country at 79.9. Compare that to Mississippi at 70.9. Life expectancy for men in Mississippi is on par with men in Ethiopia. And while we hear so much about how poorly CA is governed, it also has among the highest life expectancies in the country. Places like Mississippi, Alabama, WV, OK are at the bottom.
I’m heartened to read this article and the comments as a reminder of how our government is supposed to function, with compromises between political factions working towards the greater good of ALL their constituents.
As a MA resident for most of my life (with brief stays in VT and RI), I’m nostalgic for the days when Republicans were like my former governors Romney and Baker. They are the reason I remained firmly an independent up until this point. In fact, MA residents are pragmatic people and not all “flaming lunatic leftist coastal elite” (their categorization not mine) that MAGA would have you believe.
But last month I officially joined the Democratic Party so that I can participate in the party’s upcoming state convention. The Republicans no longer represent any part of my values. And I’d rather put my energy towards shaping the one viable option remaining.
If you go to any state and scratch beneath the surface, you're bound to find all sorts of problems and challenges. For example, here in MA there is near-universal resistance (on the part of the Administration and Legislature) to independent auditing of state finances, but in balance I think we're in a far better position compared to other states.
As a lifelong MA resident it has been encouraging to see people and groups with very divergent interests and goals able to come together and formulate legislation that functions fairly well for a good chunk of the population. Believe it or not, this is the way it used to work in Washington as well.
This quote: ”But Travaglini struck a serious note too, recalling that “we were capable of putting aside egos, personalities, party affiliations for the good of the people that we represented.” It explains why we are in such a desperate mess. No one on the Republican side seems capable of that anymore.
I do not understand this american health caredisaster. I have had universal health care most of my life, I ay for it with my taxes ca 10procent, but there is nolimitsof care aftermy needs. I also pay a small fee when I visit a clinic or the hospital for specialist . As of today I pay ca 20 dollar to clinic or 30 to specialis which include everything, except medicin which has special subsedives. There are no limitations more than what is necessary. During a 12 month period I do not pay more than 240 dollars in fee. If in hospital Ido not pay more tha some dollars for my food,everything else is covered. I do not need to show insurence when I go to hospital or clinic only my ID card or driverslincence. SOi really do not understand the american system
I'm willing to bet that with our current president, in his 2nd terms, there's a heck of a lot more about us that you can't figure out, and consider a disaster!
(Many of us here in the U.S., possibly most Cohn readers, can't understand it ourselves. All of it. And many of those get hopelessly depressed by it.)
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Actually, on long-term-care like nursing homes, we may be even more bad than you think. People here generally have to pay $90,000 to $160,000 a year for nursing homes, until they become dirt poor in both income and assets, and then our Medicaid program, designed for the dirt-poor in income and assets, picks it up.
I did determine that for nursing homes, the U.K. is like here in the U.S.: you have to spend down to being pretty poor before the government pays. Not so in many other countries, though. How well the system protects people I could not always establish.
(On Norway, if you happen to know off the top of your head, by all means chime in if you have the time.)
I know Sweden better than Norway. In Sweden municipality is responsable for care of the elderly that can´t take care of themself. (or have demetia) You pay as far as I knowrent for your "apartment, you get helo around the clock , fodd is delivered. You pay according to income, but is garantid a sum every month for medicin, clothes and wharever, As long as possible you ae supposed to live in your own dwelling and get help in yur there. Then you pay your rent (or morgage or cost for utilities according to income. You can get help with personal or nurses is necesassary.. Tere is special buldings where you can rent according to age, for example over 6o , where you pay rent normally and if you need get heklp inyour home. you aalways pay for helo according to need and income. It is all paidfor by taxes from us all,
The municipalities is responsable forall servite to the inhabitants, like child care which is garanted from 12 months old children (we have 12 months materntivleave with 90 procent income) We pay even here acoording to income. We pay about 20 procent in tax to the municipality.which means that the poor (?) pay less for help.
If your child is sick, you canstay home with your child and get 90 procent of your income. We pay eve morevaluetax,. We have a national insurencewho adminterall this,like 90 procent of income if you aresick yourself. More tan 70 procent of women work , we have very little of homemakers.
Schoolisfree 12 years, everybody have free lunch in school. Universityi free, you can get a loan fo supportyourself during your years when you study with resonable morgage which you pay according to income. All americans I have talked to about thissystemalways say;bu you pay so much taxes, maybe we do, but we get a lot back and a safetysystem that gives service when needed
It often takes us far longer to accomplish things in the US (especially compared to our neighbors up north). There are u-turns, backsteps, and detours along the way, but the greater trendline is forward movement.
I understand ths. Also compared to the Cuntries in Europe you have more difficulties to get all the states on the same idea. But I read an articel about "Romneycare" and that could be a way to start. And of course the unions in Europe is stroger, have more influence and they have pressed on the government. Then you have the insurance- companies which has a lot of power they don´t want to loose. But I wish you all the luck to in the work to getter abetter healthcare
I remember this time with…fondness? I cut my consulting analytical teeth attempting to untangle the boondoggle Massachusetts used to pull down a hefty amount of federal funding through its hospitals which led to the “gun to the head”. They certainly had a fiscal incentive to come up with a solution. Those of us working in the policy arena of publicly financed healthcare generally applauded Massachusetts’ approach. And if states were listening to consultants, they were hearing that Massachusetts proved the US could get pretty darn close to universal coverage.
I'm always dismayed when Republicans, even normal ones like Romney, castigate us "loony lefties" for policies like health care for all, trying to lower student debt, and respect for LGBTQ+ Americans. Then they support mass deportation of people who've never committed a crime by masked thugs who kill people to do it, and excuse it with lies that they're terrorists. They cut health insurance and food assistance to the poor so they can cut taxes for the rich. And they eviscerate every protection the federal government offers to keep Americans from being defrauded.
The only Democrats I blame are the ones who flipped to St. Ronnie in 1980 and laid the foundation for the current shitshow.
Thanks for this great article, Jonathan. Some additional context from a nearly lifelong Massachusetts resident who remembers the arrival of Romney Care well that you may appreciate:
1) It was about the hospitals, and the hospitals in Massachusetts are power players in a way they may not be in other states. It's not just about the health of the state's citizens--health care and education are big industries/sectors in Greater Boston employing a lot of people. There are three major medical schools in Boston--which is a lot for a city of 700,000 or so. The boards of these hospitals have included some of our most connected and influential power brokers including the legendary PR/advertising king Jack Connors, who was a longtime board member of Mass General, and Thomas P. O'Neill III, former lieutenant governor and son of Speaker Tip O'Neill, who served on the boards of Mount Auburn Hospital.
2) You note that Romney Care survived and thrived under a Republican governor as well as two Democrats. That Republican was Charlie Baker, who, prior to becoming governor in 2015, had served as the leader of the state's largest insurer, Harvard Pilgrim Health Care, and who had saved it from insolvency. This was a sector he knew well and was already committed to.
3) Finally, this may be the most important. I'm not sure why, but the for-profit health insurance industry never got a good foothold here in the state. The biggest players then were Harvard Pilgrim, Blue Cross and Tufts Health Plan (since merged with Harvard Pilgrim). Sure, you can buy United Health here, but I believe every employer offers at least one non-profit version and five of the top six plans in the state (or so the AI tells me) are not for profit. Had United Health Care been a bigger player here, I think they would have put up more of a fight.
I miss those days when politicians wanted to work together for the good of their constituents. I always admired Romney and this article reminded me why.
Those were the days!
I've just gone beyond reading the post to watching the video of the Romney interview as well. It was a great interview. (Perhaps Bulwark will let go of its IP rights on it, and release it on YouTube.)
1) I find a major misrepresentation or misunderstanding from Romney in it, though.
Based on this fact: For a person showing up at an emergency room, regardless of insurance status, the emergency room (due to the Reagen-era EMTALA law)
a) has the legal obligation to stabilize them only,
b) and the person is legally responsible for the bills afterwards.
(Digression on info source: I have been able to verify this easily from reliable sources via search engines when I double checked the info months and years ago, though today google changes seem to be making it a tougher job, with the google AI getting confused by less-reliable Reddit posts and such, that I don't deem reliable enough.
I have found this reliable-looking source:
https://triagecancer.org/emtala-emergency-medical-and-treatment-labor-act
from which I quote:
"EMTALA requires hospitals that offer emergency services and accept Medicare, to screen and then stabilize a patient with an emergency medical condition—regardless of a patient’s ability to pay.
EMTALA, does not, however, require hospitals to cure underlying medical conditions (e.g., cancer) or provide outpatient care (e.g., chemotherapy).
EMTALA is also not a substitute for health insurance. After treating a patient under EMTALA, a hospital may still bill the patient for services that they received.
Before EMTALA became law in 1986, hospitals had no federal requirement to treat uninsured patients."
I point out that much of what is turning up in my search attempts on the matter of patients being billed for EMTALA-required services is getting me to posts from our government, like at CMS, pointing out the emergency services that they have to give you at the E.R. and all of the rights you have, but seemingly taking pains to avoid saying that you are legally responsible for the bills for those emergency services. Could it be the new administration that is responsible for that?
End digression on info source.)
--
Anyway, Romney's indication that pre-Romneycare, a person with a $100,000 a year income could just not have insurance and show up at the ER and everything would be O.K. seems quite inaccurate. They could be made to pay the bills afterwards, and, as well, non-emergency care, say chemotherapy for cancer, was not part of the required ER care.
I do understand that a person might have local knowledge that a certain hospital might not bill, finding the money not worth recovering as there was not much to recover in most cases, or as an ethical decision, but this is certainly not guaranteed. It would seem to be a genuinely bad decision not to carry health insurance with an income of $100,000 a year, and presumably some savings to lose.
(I suspect Romney may know this. He is a politician. Politicians have to do the valuable work of convincing the people, who are often both silly and stupid, so I suspect he is oversimplifying and distorting intentionally.)
Yes, people at very low incomes, and with little in assets to lose, may have done OK with just EMTALA service, and whatever supplementary care they could get provided by charitable organizations, but not the higher income people.
--
2) I do not know for sure, but I suspect that with Romneycare, a certain lower income group may have had coverage that was estate recoverable. Thus, whatever 98% coverage rate in Massachusetts, or whatever was said was the rate with Romneycare in the interview, the rate was possibly incorrect in that maybe 6% of the people had an estate recoverable loan, until death, for whatever medical expenses occurred, and not any kind of insurance.
I was living in Massachusetts for 4 years of Romneycare, so I should know about whether that was the case, but I am afraid I do not. (Perhaps someone else does know an can reply.)
My suspicion of during Romneycare is because I do know that from the initial ACA going into effect in Massachusetts in 2014, until sometime in 2024, about 6% of the people in Massachusetts, those 55 and older who had ACA expanded Medicaid as coverage, had one of those loans until death for whatever medical expenses occurred, though it may actually have been real insurance, with a loan until death for the premium, for some of them. (I couldn't figure out myself which of those two it was, and I think it may have varied based on exactly how your particular expanded Medicaid program happened to be funded.)
That is because of the Massachusetts decision to estate recover ACA expanded Medicaid, from 2014 to mid 2024, under its Medicaid estate recovery rules.
(I have complained about that, and the recovery still affecting ACA expanded Medicaid in some other states, within this earlier-today comment:
https://www.thebulwark.com/p/a-bittersweet-20th-birthday-for-romneycare-mitt-romney-interview/comment/243780658 ,
and also have my own post solely devoted to, and providing references on, that issue, here:
https://normspier828307.substack.com/p/an-affordable-care-act-defect-needing ,
if anyone is interested.)
Sigh.
I feel that the mainstream news sources, disappointingly including the New York Times, do a miserable job of pointing out critical details (possibly due only to being under-resourced).
I feel that those details would benefit a portion of their readers who seek and would understand them. Thus, I continue my habit of plopping down details I have picked up from the tiny substack wonkosphere here on Jonathan Cohn, where they might be of use to some.
In this case, I am plopping down on the effects of the lapsed ACA expanded subsidies, which lapsed 1/1/26 at the insistence of the Republicans.
Based on the initially-available data, including just what happened through the end of Open Enrollment in January, these are the findings:
OPEN-ENROLLMENT RESTRICTED, NOT SPLITTING BY INCOME GROUP
About 4.9% of the 24 million people did not re-enroll. This is across all income groups considered together, and not splitting people down by income.
This available-now open-enrollment-only data has limitations that make it tend to overstate the number keeping coverage, especially because about half of the people considered re-enrolled were automatically re-enrolled, and are expected to not actually follow through and pay for coverage. Additional others are expected to drop coverage later this year or eventually, finding the premiums work out now to be too high to successfully manage.
Charles Gaba, in the data, recorded a high proportion of people keeping coverage, but downgrading from say silver to a bronze plan, (thus taking on potential excessive copays if they do get sick, with larger deductibles and out-of-pocket maxes). Like 10% or so of people moving silver to bronze from Gaba's computations: here: https://charlesgaba.substack.com/p/final-2026-open-enrollment-report-d4f?utm_source=profile&utm_medium=reader2 .
KFF has, by an alternate method, it's own survey, about 28% downgrading coverage. (here: https://www.kff.org/public-opinion/a-follow-up-survey-of-aca-marketplace-enrollees/ ), with incidentally, about 17% reporting they are not confident they can afford their premium all year.
OPEN-ENROLLMENT RESTRICTED, RESTRICTING TO OVER THE RETURNED 400% FPL SUBSIDY CLIFF
This zone of income is of special interest to me, because it's where the really humongo cost increases arise.
Thus, below 400% of FPL, people would have experienced a rise in the net premium they have to pay of up to 2% to 4.5% of their income, which would be for the same plan as without the lapsed expanded subsidies. (Many of those might have been able to bring down the increase in what they have pay by choosing a cheaper plan, which, as we know from previously mentioned data details, did actually happen.)
Above 400% of FPL, where subsidies stopped entirely with the lapse of the expanded subsidies, it is not hard to find increases of 40% of income on the net premium, with, thrown in, a jump from a mid-level plan down to the cheapest available plan in that case. Thus, in Wyoming, a 62 year old couple with an income of $88,000 a year has premium jump from about $6,000 a year to about $40,000 a year, going mid-range to cheapest available, as well.
In some other states, it's not 40% of income. Older people might still have 25% of income jumps, and in younger ones, closer to 30, it might be 5% to 20% of income. (Very roughly--I have not researched this precisely.)
Thus, one expects people over the returned 400% of FPL "subsidy cliff" might have really been thrown under the bus here, and both my look at the data:
https://normspier828307.substack.com/p/aca-2026-enrollment-after-expanded
and Charles Gaba's:
https://charlesgaba.substack.com/p/final-2026-open-enrollment-report-b83?utm_source=profile&utm_medium=reader2
show that, with similar numbers, though some of the exact computations we went after differ a little bit.
Thus, overall, we have numbers like around 38% of people in the just-over-the-cliff 400% to 500% of FPL group dropping out of being covered from 2025 to 2026, with it being even more of
a serious drop in some of the highest-premium states, like WV and WY.
However, with these complexities:
Charles and I both observed about 250,000 to 300,000 people seem to have moved themselves into the just below-the-cliff 300% to 400% of FPL income group on the exchange since 2025. Obviously, those people have either decided to work less and make less money, saving that humongo premium jump over-the-cliff, or work the same but keep profits in a corporation that they own that employs them--keeping the money outside of ACA-subsidy use. O, they were just putting in a false low number as estimated 2026 income on the exchange. (In the latter case, they will have to pay back all of the savings at tax filing time for 2026, which ends a year from today! Those are the rules, and those people will not be pleased!)
Anyway, where I or Charles has found say that 38% dropping, it is expected that some of the people in the 38% actually didn't drop, but took the work-less or try-cheating approach.
There is another slight complexity coming from that a proportion of people who appear as missing from 400% to 500% FPL group in 2026, say that 38% again, may have gotten omitted because, seeing they were not going to get a subsidy, they avoided entering an income on the exchange. (This not entering an income, if they kept coverage, would tally them as covered in 2026, but in a different group, the "unknown income" group, rather than the 400% to 500% FPL group in the released data from CMS. ) I tend to believe this number moving to unreported income because no subsidy now is small, because, all through open-enrollment, there was the possibility of a partial removal of the 400% FPL subsidy cliff in legislation that even a few Republicans in Congress were supporting. (So, entering an income would be the way to make that possible much lower premium possible automatically, without lots of work later.)
Being very conservative, though, I did a pooling method of all the over the cliff income groups with the no-income-reported group, and still found about a 16% coverage drop in that combined group. (It's a certain group, probably of mostly over the cliff people, dropping at an 16% rate. Still much higher than the overall 4.9% dropping rate. )
My intention is, eventually, to make, and post, a table where you can kind of see, in all of these over the cliff cases, how many actually dropped coverage, how many may have just lowered their income to below the cliff, with it also clear in my table which numbers are subject to possible smallish overestimates of proportion dropping from people to switching to not reporting an income on the exchange.)
BEYOND OPEN ENROLLMENT:
As time goes on, there is the expectation that many more people will drop than shown in the prior numbers from just open enrollment. Many, indeed, were auto-re-enrolled, and may never pay the premium.
Such numbers, being released at the Federal Level, are at least many months away. I am also not sure those numbers will include by-income numbers, allowing us to isolate the over-the-cliff cases.
Charles Gaba is always looking for early data, from single states with their own exchange, where we get an earlier idea.
He already has one post on Colorado, https://charlesgaba.substack.com/p/colorado-q1-effectuated-enrollment , where already he has a 5.1% higher drop rate than at the same time last year. (Further, Colorado has some partial state-financed mitigations of the subsidy increases, so it would be a state that tends to understate the eventual coverage losses across all states, most of which did not mitigate at all.)
Could you discuss how the voting system contributes to the mess? Consider two alternative ways to oppose the Democratic approach to nationalizing Romneycare: one would be to have an alternative approach drafted, cooperate with the Democratic approach, wait for flaws to become apparent in that Democratic approach, and present your alternative as a fix. The other is to do everything to sabotage the Democratic approach.
Democratic voters would universally prefer the first approach over the second. However, the current voting system would give any Republican embracing that approach zero credit for being the preferred Republican among Democratic voters. Instead, the only question that matters for any Republican politician's interests is what do the majority of highly engaged Republican voters want. With a clear majority of that group favoring the second approach, elected Republican fall in lockstep behind the approach of sabotage and display imperviousness to evidence that the Democratic approach has any merit.
All that is needed to get Republican pols to play a constructive role is a voting system that rewards the candidate who induces the most voters to say, "I'd rather a Democrat get elected, but if Republican is going to be elected, I want it to be that one."
I am pleased that Mr. Romney and Mr. Cohn covered the partisanship problem, but I noted they missed the blatant lying and deception on the Republican end, that I've particularly noted myself since a bit before the end-of-2025 government shutdown.
1)We have the overwhelmingly false Republican assertion that the Democrats were shutting the government down in order to provide healthcare to undocumented immigrants, which was made not just by POTUS, but also by:
1a)J.D. Vance, at a "press conference", where the first "reporter" to ask a question asks about "Two key Democrat lies". (Here: https://www.youtube.com/watch?v=m7W1L5iENcI&t=504s )
1b)House Speaker Mike Johnson also said (here: https://www.youtube.com/watch?v=sHtZU1Vc7k4&t=63s ):
"it is a fact, that no one can dispute, that they [the Democrats] shut the government down over restoring free healthcare to illegal aliens as part of their $1.5 trillion wild partisan wish list."
1c) For anyone interested, I have a transcript of exactly what Vance said, videos of POTUS making the assertions, and analysis where I discuss the slight element of truth in some of the assertions, based on that 1% of the money involved in the matters that the government was shut down over was for undocumented immigrants (ER care--legally required by the Reagan-era EMTALA law), perhaps an additional 7% was for "legally present" people, who are not undocumented, but who the Republicans prefer to think of as undocumented). Here:
https://normspier828307.substack.com/p/exploring-the-mass-deception-and
2) Republicans John Thune and Mike Johnson both used a graph, labelled "Obamacare Plan Premiums Have Increased Nearly 2x Faster Than Employer-Based Plan Premiums since 2014", to justify not extending the ACA expanded subsidies.
However, I'm pretty sure that graph is erroneous, owing to an omission of a major component of the cost from the ACA plans that existed between 2014 and 2017 only. As well as a different large error. When I tried, myself, to counter the errors, I got the ACA plan premiums rising either just a little more, or possibly even a little less, than the employer premiums.
Here, if interested:
https://normspier828307.substack.com/p/senate-republican-leader-john-thune
3) On a matter that only the wonky tend to follow (Cost-Sharing-Reduction financing and "silver loading"), a Republican lawsuit early in the ACA to try to weaken it succeeded, but actually wound up backfiring, and making the ACA coverage somewhat stronger.
Recently, Republicans have been trying to undo their mistake with legislation to undo the inadvertent strengthening.
However, Charles Gaba caught Dr. Oz, head of CMS himself, representing that the thing the Republicans are doing, has exactly the OPPOSITE effect--a strengthening of coverage--than the true effect--a weakening of coverage.
I also caught that opposite-of-actual-effect representation earlier, myself, in the specifications of the Crapo-Cassidy Senate bill.
(Details, for the interested, here:
https://normspier828307.substack.com/p/cost-sharing-reductions-silver-loading)
Typical Republican dishonesty:
"2) Republicans John Thune and Mike Johnson both used a graph, labelled "Obamacare Plan Premiums Have Increased Nearly 2x Faster Than Employer-Based Plan Premiums since 2014", to justify not extending the ACA expanded subsidies.
However, I'm pretty sure that graph is erroneous, owing to an omission of a major component of the cost from the ACA plans that existed between 2014 and 2017 only. As well as a different large error. When I tried, myself, to counter the errors, I got the ACA plan premiums rising either just a little more, or possibly even a little less, than the employer premiums."
Here, if interested:
https://normspier828307.substack.com/p/senate-republican-leader-john-thune
>>> " Romney made clear he thinks Democrats deserve plenty of blame for the degradation of politics—because, he said, they took actions (like using executive orders to wipe out student loans) that violated constitutional norms and staked out positions on cultural issues (like transgender athletes) that he believes made more Americans sympathetic to MAGA."
Mitt. You get points for doing the right thing, but I deduct points for hedging with this dumb bullshit. Christ's sake
I have lived in Massachusetts for about 16 years now, and in fact moved here in part because, where I was previously, upstate New York, the system they had there: pure, non-age-based community rating, without a mandate to carry coverage, was starting to experience one of those adverse-selection-based death spirals, with the cheapest plan available to me, or any one person of any age in that area, set to rise from $800 a month to $1200 a month, in a period of over less than 3 years.
Romneycare, in effect here at the time, offered me coverage for about $700 a month (without a subsidy--I declined the available subsidy).
Some notes:
1) Massachusetts still has its mandate from back in the Romneycare days. (When the ACA had a mandate, there was both a state mandate and the federal mandate.)
2) The state mandate, like the original, removed federal mandate, is probably inadequate to completely cut down the higher-price effect from significant adverse selection. Massachusetts controls the problem in a way which not many, or perhaps any, other states do. It requires actuarial pooling of small-business plans with ACA plans. (Thus, the small-businesses have much less adverse-selection, and dilute the adverse selection. Everything is a trade-off, of course. Small businesses wind up a bit worse off than they would otherwise be.)
2b) With the loss of the expanded subsidies, and the return of the 400% of FPL "subsidy cliff", the pooling of small businesses and ACA plans doesn't solve the affordability problem.
Thus, in his recent Valentine's Day discussion with Paul Krugman ( https://paulkrugman.substack.com/p/talking-again-with-jon-gruber ), Jonathan Gruber, substantially a designer of both Romneycare and Obamacare, reported:
"I have friends who are 60-year-olds in Massachusetts like me. I have a friend who’s going from paying $8,000 a year to $25,000 a year for health insurance. I don’t know what his income is, but even if your income was $100,000, that’s 25% of your income. That’s a lot of money. That’s unaffordable."
3) Let us not idealize the world, or Massachusetts, or the people and government of Massachusetts. The ACA had some pretty-good-sized problems as administered in Massachussetts, and probably still has some, from Massachusetts' imperfect handling of things. I have two in mind:
3a) Massachusetts was one of several Democratic-governed states that had a Medicaid estate recovery policy that would estate-recover from ACA expanded Medicaid recipients who were 55 or over when they had the expanded Medicaid. It was unclear, as far as I could tell, whether the state would go after an annual fixed capitation payment, or all medical bills paid out, from the estates of people who had the recovered expanded Medicaid. If it was the latter, then the person with that ACA expanded Medicaid had no health insurance at all. They had, precisely, a loan, until death, for whatever medical expenses occurred.
This was fixed, finally, in the middle of 2024 (over 10 years later than the ACA provisions started, and even later if something like it applied to Romneycare). It was fixed due to the impetus from two state legislators: Comerford and Barber.
(Before 2024, Massachusetts was boasting something like a 98% "health insured" rate, the highest in the country. I used to go around trying to correct that with that only 92% were insured. 2% were uninsured, and 6% had either a loan until death for whatever medical expenses occurred, or insurance, with a loan until death for the premium.)
Last I heard, though Massachusetts did fix this problem in 2024, Democratic NJ and MD still have the recovery problem.
(For those interested, I have details on the Medicaid estate recovery thing, as it affects ACA expanded Medicaid, on my post here:
https://normspier828307.substack.com/p/an-affordable-care-act-defect-needing )
3b) In my roughly 8 years using the ACA in Massachusetts, I also caught an apparently unstoppable tendency of the state to reclassify people from expanded Medicaid (income below 138% FPL) to subsidized on exchange (income above 138% FPL), or in the reverse direction, absolutely as soon as they detected an income change crossing the threshold. Up to, I don't know how many times a year. Changing provider network each time!
(With the ACA being a complex part of our byzantinely-complex health insurance system, and with each of 51 states + D.C. having their own expanded Medicaid eligibility system, and many having their own ACA exchange, undoubtedly all kinds of states have similar custom problem sets afflicting their populations. I have noted here:
https://normspier828307.substack.com/p/one-of-many-problems-coming-from
and elsewhere, that the new more-frequent (at least twice a year) eligibility checks for expanded Medicaid, as well as the work requirements, will expand the miseries of people, as the 51 states tackle the new requirements in their own, customized way. (The excess thrashing up and down between expanded Medicaid and on exchange that I reported in Massachusetts is now forced on all states by the twice-a-year expanded Medicaid eligibility evaluations.)
This article was equivocal about whether people are healthier because of Romneycare. On the most basic measure of health and wellbeing—life expectancy—MA is #2 in the country at 79.9. Compare that to Mississippi at 70.9. Life expectancy for men in Mississippi is on par with men in Ethiopia. And while we hear so much about how poorly CA is governed, it also has among the highest life expectancies in the country. Places like Mississippi, Alabama, WV, OK are at the bottom.
I’m heartened to read this article and the comments as a reminder of how our government is supposed to function, with compromises between political factions working towards the greater good of ALL their constituents.
As a MA resident for most of my life (with brief stays in VT and RI), I’m nostalgic for the days when Republicans were like my former governors Romney and Baker. They are the reason I remained firmly an independent up until this point. In fact, MA residents are pragmatic people and not all “flaming lunatic leftist coastal elite” (their categorization not mine) that MAGA would have you believe.
But last month I officially joined the Democratic Party so that I can participate in the party’s upcoming state convention. The Republicans no longer represent any part of my values. And I’d rather put my energy towards shaping the one viable option remaining.
If you go to any state and scratch beneath the surface, you're bound to find all sorts of problems and challenges. For example, here in MA there is near-universal resistance (on the part of the Administration and Legislature) to independent auditing of state finances, but in balance I think we're in a far better position compared to other states.
As a lifelong MA resident it has been encouraging to see people and groups with very divergent interests and goals able to come together and formulate legislation that functions fairly well for a good chunk of the population. Believe it or not, this is the way it used to work in Washington as well.
This quote: ”But Travaglini struck a serious note too, recalling that “we were capable of putting aside egos, personalities, party affiliations for the good of the people that we represented.” It explains why we are in such a desperate mess. No one on the Republican side seems capable of that anymore.
I do not understand this american health caredisaster. I have had universal health care most of my life, I ay for it with my taxes ca 10procent, but there is nolimitsof care aftermy needs. I also pay a small fee when I visit a clinic or the hospital for specialist . As of today I pay ca 20 dollar to clinic or 30 to specialis which include everything, except medicin which has special subsedives. There are no limitations more than what is necessary. During a 12 month period I do not pay more than 240 dollars in fee. If in hospital Ido not pay more tha some dollars for my food,everything else is covered. I do not need to show insurence when I go to hospital or clinic only my ID card or driverslincence. SOi really do not understand the american system
I'm willing to bet that with our current president, in his 2nd terms, there's a heck of a lot more about us that you can't figure out, and consider a disaster!
(Many of us here in the U.S., possibly most Cohn readers, can't understand it ourselves. All of it. And many of those get hopelessly depressed by it.)
--
Actually, on long-term-care like nursing homes, we may be even more bad than you think. People here generally have to pay $90,000 to $160,000 a year for nursing homes, until they become dirt poor in both income and assets, and then our Medicaid program, designed for the dirt-poor in income and assets, picks it up.
I've tried to research this a bit myself (here: https://normspier828307.substack.com/p/paying-for-nursing-homes-and-long ), though I can't get good enough information for some of the other developed countries.
I did determine that for nursing homes, the U.K. is like here in the U.S.: you have to spend down to being pretty poor before the government pays. Not so in many other countries, though. How well the system protects people I could not always establish.
(On Norway, if you happen to know off the top of your head, by all means chime in if you have the time.)
I know Sweden better than Norway. In Sweden municipality is responsable for care of the elderly that can´t take care of themself. (or have demetia) You pay as far as I knowrent for your "apartment, you get helo around the clock , fodd is delivered. You pay according to income, but is garantid a sum every month for medicin, clothes and wharever, As long as possible you ae supposed to live in your own dwelling and get help in yur there. Then you pay your rent (or morgage or cost for utilities according to income. You can get help with personal or nurses is necesassary.. Tere is special buldings where you can rent according to age, for example over 6o , where you pay rent normally and if you need get heklp inyour home. you aalways pay for helo according to need and income. It is all paidfor by taxes from us all,
The municipalities is responsable forall servite to the inhabitants, like child care which is garanted from 12 months old children (we have 12 months materntivleave with 90 procent income) We pay even here acoording to income. We pay about 20 procent in tax to the municipality.which means that the poor (?) pay less for help.
If your child is sick, you canstay home with your child and get 90 procent of your income. We pay eve morevaluetax,. We have a national insurencewho adminterall this,like 90 procent of income if you aresick yourself. More tan 70 procent of women work , we have very little of homemakers.
Schoolisfree 12 years, everybody have free lunch in school. Universityi free, you can get a loan fo supportyourself during your years when you study with resonable morgage which you pay according to income. All americans I have talked to about thissystemalways say;bu you pay so much taxes, maybe we do, but we get a lot back and a safetysystem that gives service when needed
Baby steps.
It often takes us far longer to accomplish things in the US (especially compared to our neighbors up north). There are u-turns, backsteps, and detours along the way, but the greater trendline is forward movement.
I understand ths. Also compared to the Cuntries in Europe you have more difficulties to get all the states on the same idea. But I read an articel about "Romneycare" and that could be a way to start. And of course the unions in Europe is stroger, have more influence and they have pressed on the government. Then you have the insurance- companies which has a lot of power they don´t want to loose. But I wish you all the luck to in the work to getter abetter healthcare
I remember this time with…fondness? I cut my consulting analytical teeth attempting to untangle the boondoggle Massachusetts used to pull down a hefty amount of federal funding through its hospitals which led to the “gun to the head”. They certainly had a fiscal incentive to come up with a solution. Those of us working in the policy arena of publicly financed healthcare generally applauded Massachusetts’ approach. And if states were listening to consultants, they were hearing that Massachusetts proved the US could get pretty darn close to universal coverage.
I'm always dismayed when Republicans, even normal ones like Romney, castigate us "loony lefties" for policies like health care for all, trying to lower student debt, and respect for LGBTQ+ Americans. Then they support mass deportation of people who've never committed a crime by masked thugs who kill people to do it, and excuse it with lies that they're terrorists. They cut health insurance and food assistance to the poor so they can cut taxes for the rich. And they eviscerate every protection the federal government offers to keep Americans from being defrauded.
The only Democrats I blame are the ones who flipped to St. Ronnie in 1980 and laid the foundation for the current shitshow.
And Republicans also cripple the IRS every time they are in power, jettisoning staff and reducing the appropriation.
In what universe does impoverishing the only tax collection agency for our country make sense?
Thanks for this great article, Jonathan. Some additional context from a nearly lifelong Massachusetts resident who remembers the arrival of Romney Care well that you may appreciate:
1) It was about the hospitals, and the hospitals in Massachusetts are power players in a way they may not be in other states. It's not just about the health of the state's citizens--health care and education are big industries/sectors in Greater Boston employing a lot of people. There are three major medical schools in Boston--which is a lot for a city of 700,000 or so. The boards of these hospitals have included some of our most connected and influential power brokers including the legendary PR/advertising king Jack Connors, who was a longtime board member of Mass General, and Thomas P. O'Neill III, former lieutenant governor and son of Speaker Tip O'Neill, who served on the boards of Mount Auburn Hospital.
2) You note that Romney Care survived and thrived under a Republican governor as well as two Democrats. That Republican was Charlie Baker, who, prior to becoming governor in 2015, had served as the leader of the state's largest insurer, Harvard Pilgrim Health Care, and who had saved it from insolvency. This was a sector he knew well and was already committed to.
3) Finally, this may be the most important. I'm not sure why, but the for-profit health insurance industry never got a good foothold here in the state. The biggest players then were Harvard Pilgrim, Blue Cross and Tufts Health Plan (since merged with Harvard Pilgrim). Sure, you can buy United Health here, but I believe every employer offers at least one non-profit version and five of the top six plans in the state (or so the AI tells me) are not for profit. Had United Health Care been a bigger player here, I think they would have put up more of a fight.