With the Supreme Court on Thursday upholding President Obama’s health care law, Mr. Romney faces increased pressure to flesh out alternatives to the law that he and other Republicans despise. Although Mr. Romney has repeatedly stressed his opposition to a federal mandate to buy insurance — a crucial provision of Mr. Obama’s law, modeled on a mandate Mr. Romney enacted as Massachusetts governor — he has devoted less time to describing his own health policies. But in speeches in the past year, he has made clear that he favors tax breaks, increased competition and devolving decisions to states to make health care more affordable, proposals that reflect a consensus on health policy that has solidified in the last decade among Republicans. Mr. Romney’s preferences, like those being proposed by Republicans in Congress, would put more emphasis on controlling health costs and less on reducing the ranks of the uninsured, the primary goal of the Obama plan. Conservatives say the new law does not seriously address rising health costs, a major factor in the high cost of insurance. One of Mr. Romney’s chief proposals could shake up how the vast majority of Americans get health care — through employers. He would give a tax break to people who buy insurance individually on the open market, so they would enjoy the same advantage as workers who get insurance as a benefit at work, which is not taxed as income. Aides to Mr. Romney said tax parity would introduce more consumer awareness of the costs of health insurance, and competition among insurers would drive down costs. A tax incentive to buy insurance “has the potential to be significant,” said Lanhee Chen, Mr. Romney’s policy director. “It can be something that really moves our health care system in a good direction.” Democrats warn that under such a system fewer employers will choose to offer health insurance, and older and sicker workers will be thrown into the market for individual insurance that they cannot afford. When Senator John McCain proposed in 2008 to offer a $5,000 tax credit to families for health insurance, independent analysts estimated that the ranks of the uninsured would rise by one million, to 21 million people. To make insurance affordable for low-income people or the chronically ill, Mr. Romney would encourage states to experiment with high-risk pools, offering subsidies to the poor and insurance-buying exchanges — in essence, harnessing the purchasing power of large groups. Mr. Obama’s law currently encourages states to establish similar exchanges, a page taken partly from a successful exchange in Massachusetts created by Mr. Romney. But as the presumed Republican presidential nominee, Mr. Romney opposes a federal requirement that all states follow the Massachusetts example. In state legislatures around the country, conservative Republicans have often resisted creation of health insurance exchanges. Still, one of Mr. Romney’s top advisers, Michael O. Leavitt, the former secretary of health and human services, has advised a half-dozen states about how to set up exchanges. “An exchange can greatly expand the number of insurance choices available to employees of small businesses,” said W. Brett Graham, a partner in Mr. Leavitt’s health care consulting business. One of the most ambitious changes Mr. Romney would enact is to transform Medicaid, which insures more than 50 million poor and disabled Americans, into a program of block grants, or lump-sum payments, to states. Grants would be capped to rise at the Consumer Price Index plus 1 percent a year. The block-grant system that Mr. Romney supports is similar to a proposal in the House Republican budget fashioned by Representative Paul D. Ryan of Wisconsin in an effort to slow rapid growth of the program. Democrats argue that turning Medicaid into a block-grant program with a cap would force states to cut vulnerable people from the rolls or reduce services as health care costs spiral. “The vast majority of people on Medicaid are children and mothers,” said Neera Tanden, president of the Center for American Progress and a former health care adviser in the Obama administration. “I think it is cruel to drop coverage” for them.
