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Of all the items in Mitt Romney's political record, few are more awkward than the health-care law he signed in Massachusetts, in 2006. It extended insurance coverage to the overwhelming majority of people, while still relying on private companies. What's problematic is that Republicans want to make the 2012 elections a referendum on the health-care law that President Obama signed. And so Romney's opponents in the presidential race are attacking him on it - as Rick Santorum did in a South Carolina debate.

(SOUNDBITE OF DEBATE)

RICK SANTORUM: He put forth Romneycare, which was not a bottom-up, free-market system. It was a government-run health-care system that was the basis of Obamacare, and it has been an abject failure. And he has stood by it.

INSKEEP: NPR's Richard Knox now begins a series on Romneycare - as Senator Santorum and others call it - which is not controversial in its home state.

RICHARD KNOX, BYLINE: A lot of people here in Massachusetts don't call it Romneycare, because it took the support of a lot of other people to get it passed. But it's true Romney got the ball rolling. When I interviewed him in 2006, he said he got the idea talking to Massachusetts business leaders.

(SOUNDBITE OF ARCHIVED INTERVIEW)

MITT ROMNEY: The key insight was this: People who don't have insurance nonetheless receive health care, and it's expensive.

KNOX: Romney saw that a state fund that provided free care - paid for by a surcharge on private insurance - was spending a billion dollars a year.

(SOUNDBITE OF ARCHIVED INTERVIEW)

ROMNEY: My question was: Could we take that billion dollars and help the poor purchase their insurance? Let them pay what they can afford; we'd subsidize what they can't.

KNOX: And he proposed a requirement that people buy private health insurance if they're able.

(SOUNDBITE OF ARCHIVED INTERVIEW)

ROMNEY: We're going to say folks, if you can afford health care then gosh, you'd better go get it. Otherwise, you're just passing on your expenses to someone else. That's not Republican; that's not Democratic; that's not Libertarian. That's just wrong.

KNOX: The Massachusetts plan has had strong and steady support, and little opposition. Last year, an attempt to repeal the part that requires most people to have insurance couldn't get enough signatures. Only 39 people have liked its Facebook page.

And the current governor, Democrat Deval Patrick, says the health plan Romney launched is working.

GOV. DEVAL PATRICK: I think it's just been a terrific success, and a statement of value - about our values here; about how, you know, people are not all on their own, that we are in this together.

KNOX: To find out how it's working, I stopped by the office of Dieufort Fleurissaint, a self-employed, Haitian-American businessman.

DIEUFORT FLEURISSAINT: Richard.

KNOX: Hi.

FLEURISSAINT: How are you doing? I'm sorry for the wait.

KNOX: It's a busy place here.

FLEURISSAINT: It's busy. It's a time, you know, that's the - income taxes season.

KNOX: Fleurissaint has a tax preparation and insurance business. He's also a pastor who has worked with a group called Greater Boston Interfaith Organization, that helped get the health law passed.

FLEURISSAINT: Close to 500,000 people didn't have health insurance. Because of the passing of the law, they have health insurance.

KNOX: And one of them, it turns out, is Fleurissaint. He used to be a mortgage broker, but his business crashed in 2008. He couldn't pay his health insurance premiums. But under the new law, he qualified for state-subsidized insurance.

FLEURISSAINT: My premium just dropped from 1,200 on a monthly basis, and paid $770 for the same coverage for the same family of four.

KNOX: And when his income dropped again, so did his health insurance premium.

FLEURISSAINT: The law has been extremely good for me and also, just to many other low-income families.

KNOX: But, he admits, not all of his business colleagues like the law.

FLEURISSAINT: They complained the fact that they're, you know, they were forced, basically, obligated just to purchase health insurance. So I explained to them it's much better just to have health insurance than not having it.

KNOX: In fact, contrary to some predictions, there's been a substantial jump in the percentage of Massachusetts businesses offering insurance.

When I called the Massachusetts Restaurant Association, they said they didn't know of any restaurants that don't offer coverage. That surprised me. In the past, restaurant owners have been among the most opposed to health laws like this one. And the nationally controversial individual mandate, which requires citizens to buy health insurance if they can afford it, hasn't proved to be such a big deal.

Andrew Dreyfuss is president of the state's largest insurer, Blue Cross-Blue Shield.

ANDREW DREYFUSS: Individual mandate has not been controversial in Massachusetts.

KNOX: The sky didn't fall?

DREYFUSS: The sky did not fall and, by the way, we have much stronger penalties around the individual mandate than the national law does. And despite that, the sky did not fall.

KNOX: The penalty for not buying insurance can be on the order of $1,200 a year for a 37-year-old, single person in Boston. But only about 1 percent of taxpayers end up paying any penalty.

Meanwhile, a new survey in the journal Health Affairs shows that more Massachusetts citizens are seeing a doctor regularly. Fewer are going to emergency rooms for care. And the percentage who rate their health as good or excellent is going up.

That doesn't mean everything about Massachusetts health care is wonderful. The 2006 law didn't do anything about controlling health costs, which were already among the nation's highest. Dreyfuss says that's at the top of the agenda now.

DREYFUSS: When suddenly every employer is offering insurance, everyone is paying for it and the government is subsidizing it, and it's growing at 8 or 10 percent per year - year over year - suddenly, there's a lot more interest in doing something about it.

KNOX: Because everybody recognizes that Massachusetts can't keep requiring people to buy health insurance if they can't afford it. Tomorrow, we'll look at how Massachusetts is tackling that big problem.

Richard Knox, NPR News, Boston.

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