He favored exchanges and was 'open to' mandates. Then he ran for president.
WASHINGTON - In his presidential campaign autobiography, "Courage to Stand," former Minnesota Gov. Tim Pawlenty recalls a man in a wheelchair who approached him at an airport in Mankato.
As Pawlenty knelt to listen, the man explained that he had no money, no job and no family to take care of him. "Please don't cut my health care," the man said in a raspy voice.
"You can't experience a moment like that without being emotionally impacted," Pawlenty wrote, describing some of the wrenching decisions he faced as governor, including his move last year to end a state health program for low-income singles.
Now, as he rails against "Obamacare," the landmark federal health care law, Pawlenty makes a virtue of his eight years as governor of a state with one of the best health care systems in the nation, one that's often held up as a model for market reforms that improve quality, increase efficiency and contain costs.
But to some health care experts -- including some whose counsel he sought as governor -- Pawlenty's critique of Obamacare is a tale of two governors: From one who embraced the goal of universal coverage to one more focused on budgets, costs and what he calls "timeless conservative principles."
Former U.S. Sen. David Durenberger, chairman of Pawlenty's 2004 Citizens Forum on Health Care Costs, describes the former governor as "a guy who didn't ignore the problem."
But Durenberger noted that President Obama's Affordable Care Act contains many of the bipartisan reform ideas pioneered on Pawlenty's watch in Minnesota, including consumer health incentives favoring low-cost insurance and new quality measures for doctors and hospitals.
Pawlenty's new talking points, Durenberger argues, are "unworthy of a governor of a state that has been working hard to create many of the care system and access innovations that the Affordable Care Act will help to fund with federal dollars as an example to the rest of the country."
Former state Human Services Commissioner Cal Ludeman, Pawlenty's point man on health care, says that while Pawlenty tinkered with many bipartisan ideas as governor, he ultimately settled on a free-market approach that ruled out Obama's individual insurance mandate.
"When he says market forces, he means it," Ludeman says.
Pawlenty has used the distinction as a way to undermine GOP front-runner Mitt Romney, who signed a universal mandate as governor of Massachusetts that Pawlenty dubbed "Obamneycare."
Following Pawlenty's reluctance to confront Romney directly in a July 13 GOP debate, Pawlenty ran ads in Iowa that boasted he "did health care reform the right way. No mandates. No takeovers."
But the comparison with Romney is not necessarily flattering for the Minnesota model some pundits now call "Pawlentycare."
Massachusetts saw its rate of uninsured residents drop dramatically under Romney's health care plan. Under Pawlenty, Minnesota's uninsured rose from 6.6 percent in 2000 to 9 percent by 2009.
Pawlenty's backers say the difference was Massachusetts' mandate that individuals carry health insurance in the same way drivers must carry vehicle insurance -- a requirement that has become anathema to Pawlenty and everyone else in the GOP field.
Change of view
But that wasn't always Pawlenty's take on Romney's plan.
In 2006, Pawlenty praised Romney for attacking health care costs, said he was "open to" a similar insurance mandate and endorsed the idea that "everybody should be in a health plan of some sort."
A recording of Pawlenty's 2006 remarks has gone viral on conservative websites, getting airplay on a recent Laura Ingraham radio show with U.S. Rep. Michele Bachmann, Pawlenty's Minnesota rival in the GOP race.
"It just doesn't fly," Andy Aplikowski, a conservative Minnesota blogger who supports Bachmann, said of Pawlenty's comments.
To Ludeman, Pawlenty's remarks meant nothing more than that "he didn't want to close off the discussion about the mandate."
That same year, Pawlenty startled many by calling for extending health care access to up to 90,000 uninsured children as a step toward coverage for all Minnesotans.
'Toward universal coverage'
"We all, I think, can chart a path toward universal coverage," he said in a luncheon speech to a Minneapolis health reform conference. "We're going to have to move in stages. ... We should start with covering all kids."
In 2007, Pawlenty asked the Legislature to create a state-regulated health insurance exchange for individual health insurance policies -- now the centerpiece of Obama's plan to expand access to those who don't have group insurance through their employers.
Pawlenty's plan lacked an individual insurance mandate but would have required all individual health insurance policies in the state to be purchased through the exchange. That proposal failed in the Legislature and was shelved.
After the federal health care overhaul became law, Pawlenty joined 26 governors and state attorneys general in a legal challenge that appears headed to the U.S. Supreme Court.
Last year, as part of an executive order to prevent Minnesota from using federal funds related to the new law, Pawlenty turned down $1 million from Washington to set up a similar exchange. He cited a 2008 state Health Department study that found it would have only a "minimal impact" on costs.
"It seems like there were two Pawlentys with regard to health care," said state Rep. Paul Thissen, a DFL leader who served on the governor's bipartisan Health Transformation Task Force.
Reviews of Pawlenty's health care actions have been mixed.
Last month, the conservative Club for Growth faulted Pawlenty for the 2008 law he signed that expanded parts of MinnesotaCare, the state subsidized health insurance program for the poor. They also praised him for a plan that gave employers more flexibility in the coverage they provide.
Health care consultant Michael Scandrett, staff director of Pawlenty's health care citizens' forum, said he detected a notable change in the governor's perspective as he came closer to a run for national office.
To Scandrett, the same governor who had introduced model reforms for the care of the chronically ill morphed into a fiscal hawk focused on eliminating rather than reforming costly programs.
"It was more slash and burn than reform," Scandrett said.
The final showdown came last year, when Pawlenty moved to eliminate the program for low-income singles known as General Assistance Medical Care (GAMC).
DFLers balked, and a compromise was reached that allowed fixed payments to hospitals to care for indigents.
Critics noted that only a handful of Twin Cities hospitals agreed to participate in the program -- all at a loss -- leaving thousands of outstate patients without access to care or getting costly, uncompensated emergency room care.
Meanwhile, premiums continued to skyrocket.
"Whatever he says he did, it didn't show up in anybody's pocketbook in Minnesota," said state Sen. Linda Berglin of Minneapolis, the top DFLer on the Health and Human Services Committee before announcing July 25 that she is stepping down.
Lately, Pawlenty has taken to hawking his reforms of a state employee health plan that controlled premiums by giving cost breaks to those who chose the cheapest plans.
Health care, Pawlenty said, "needs to look more like a cash bar than an open bar."
Kevin Diaz is a correspondent in the Star Tribune Washington Bureau.