Preston's blueprint

Long before Mitt Romney unveiled his ambitious plan to provide health insurance to everyone in Massachusetts, he had Ron Preston -- ''the best health and human services secretary in the nation," the governor once called him -- working hard on a plan to do in the Commonwealth what no other state has been able to do. Romney took the wraps off his vision in November 2004, and Preston, apparently no longer the best health and human services secretary in the nation, was nudged out by the next May.

Preston and a tight group from inside and outside the administration spent six months answering Romney's basic question: Could it be done? Their answer: Yes, Massachusetts could insure all its residents. But how the Preston working group planned to do it differed, in critical aspects, from what Romney eventually proposed.

The essential divide between the governor and his human services chief was money. Romney says his plan can work with no new money; Preston disagreed. The Preston group proposed assessing a fee on employers of $150 a month for every full-time employee they do not cover, which would have raised an estimated $951 million a year. Romney opposes any kind of employer mandate, including a disputed (and ill-timed) payroll tax favored by House Speaker Sal DiMasi.

Preston's blueprint for expanding healthcare is contained in a white paper written for the governor in May 2004. Until now it has never seen the light of day. It would make good bedtime reading for legislators now at loggerheads over healthcare reform. ''For everyone to benefit, everyone must contribute and compromise," Preston wrote. ''Providers, employers, and individuals have their parts."

The 27-page document contains many of the themes that are central to the Romney plan, including a mandate that all individuals have health insurance and low-cost policies in the range of $230 a month for individuals. But it was on the questions of the essential need for new funding and an employer mandate that Romney and Preston parted ways.

''The program must be fair," Preston wrote. ''Everyone must share in its benefits and burdens. Employers who currently pay nothing toward their employees' insurance must contribute something."

The employer mandate has become the major roadblock to a grand compromise on Beacon Hill. DiMasi, the speaker, has proposed a payroll tax of 5 to 7 percent on employers who do not offer insurance to their workers. The Senate president, Robert Travaglini, wants to bill employers that don't offer insurance when their employees show up at the emergency room. Romney opposes both ideas.

Preston favored a fee, not a tax. ''Obtaining this money through a broad-based tax would induce employers who are now sponsoring insurance to drop it, placing an even greater burden on taxpayers," he wrote at the time. But in an interview yesterday he acknowledged there's not much difference between a fee and a tax. His plan ''reminds you of the DiMasi plan, doesn't it?" Preston asked. ''This is no accident." He adds that the ''governor's position is not unreasonable."

The governor's office declined to comment.

With job creation in Massachusetts badly lagging the nation, this is no time for a payroll tax on employers. And there is mounting evidence that DiMasi's numbers don't work. Business has been loud in opposition. It is clear what business is against; it is not nearly as clear, however, what business is for.

''If our proposal goes anywhere, its elements will undoubtedly be heated, cooled, split, and recombined. But our premise will stand," wrote Preston, who is now at the University of Massachusetts Medical School. ''Everyone must pay some or give some, and most must do both. If we all do our parts, we can do this task. We will see everyone insured, and we will thereby lay a foundation for a better Commonwealth and a better health care for all."

It is a sound premise.

Steve Bailey is a Globe columnist. He can be reached at bailey@globe.com or at 617-929-2902.