Before the debt ceiling and deficit-reduction debates engulfed the national political dialogue, health care was shaping up to become a cornerstone of the debate leading up to the next presidential election.
Three of the GOP presidential candidates have already fought health care battles as governors. Former Massachusetts Gov. Mitt Romney and former Utah Gov. Jon Huntsman overhauled their states' health care system while in the governor's mansion, while Texas Gov. Rick Perry has overseen an array of women's health and family planning legislation during his 10-year tenure.
"Governors control a lot about what happens in the health care system in their state, although they are also in part stuck with the hand they're dealt," said Larry Levitt, senior vice president at the Kaiser Family Foundation. "Massachusetts and Texas are very good contrasts in both cases."
The health care legislation that Romney championed while governor has become a kicking post for his fellow presidential contenders because it so closely mirrors the Republican-hated Affordable Care Act that President Obama signed more than a year ago.
Former presidential candidate Tim Pawlenty, who dropped out of the race last weekend, even coined the term "Obamneycare" to tie the former Massachusetts governor to the health care law that the president looked to as a "blueprint for his plan."
The Massachusetts law requires all residents to purchase health insurance and all employers to pay for a portion of their employees' insurance. It also creates a state exchange that provides subsidized insurance to people who cannot afford it.
At a town hall meeting Monday, Obama said Romney's health legislation is "the exact same thing" as the law he enacted at the federal level.
"You've got a governor who's running for president right now who instituted the exact same thing in Massachusetts," Obama said on the first top of his Midwest bus tour. "It's like they got amnesia."
Jon Huntsman also looked to the Massachusetts plan when designing his health care law as governor of Utah in 2007, Politico reports. Huntsman's administration ultimately shied away from a personal mandate because it more than likely would not have passed the Republican-controlled state legislature.
"When you are deliberating something as important as health care reform you look and analyze every conceivable option," Huntsman told the Huffington Post in June. "You look at everything, you analyze every possible approach, you bring in the experts and then you make a decision. And our decision was to move forward with a market-based model. And I do believe that that's likely where this country is going longer term."
The Utah law created a private employer exchange for health insurance rather than the public pool created in Massachusetts. The former Utah governor has now become an outspoken opponent of requiring people to buy insurance.
"You can either look at the heavy-handed government-centric mandate enforcing people's behavior, which in cases like Massachusetts, we have seen premiums rise substantially ... or you can create a free market based exchange, which we chose in Utah," Huntsman said, according to the Boston Globe.
But Romney argued that he only supported the personal mandate because it was right for his state, not the entire country.
"Our plan was a state solution to a state problem. [Obama's] is a power grab by the federal government to put in a place a one-size-fits-all plan," Romney said at a speech at the University of Michigan Cardiovascular Center in May. Whether or not Romney's plan is right for the country as a whole, it has achieved some of its goals within Massachusetts.
In the first three years after Romney signed the health care law, the percentage of people without health insurance dropped from 9 percent in 2001 through 2005 to 5 percent by 2009. Massachusetts now has the lowest percentage of the population without health insurance in the country.
Conversely, Texas has the highest percentage of uninsured people. In the Lone Star state, about one out of every four Texans does not have health insurance. During Perry's 10 years as governor, the uninsured rate has risen slightly from 22 percent in 2000 to 26 percent in 2009.
Levitt said Texas' high rate of uninsured people is in part because the state has a large number of retail and service jobs that typically do not provide insurance. Massachusetts, on the other hand, has a lot of high-tech employment and jobs that come with insurance packages.
"A lot of people in Texas are starting off behind the eight-ball because they aren't starting off with jobs that offer health insurance," Levitt said. "A lot of that is simply endemic to the structure of a state."
One thing governors can control is state spending on Medicaid, which affects how many people qualify for the low-income insurance program. Texas has "one of the stingier Medicaid programs" Levitt said, so fewer Texans can rely on public insurance.
Perry has attacked both Romney and Obama for what he called their "socialist proposals" of requiring everyone to have health insurance.
"Mandates are both painful to rank-and-file Texans and also extremely ineffective. Don't ask me, ask Massachusetts. In the Bay State, where a mandate is already a fact of life, premiums are 40 percent more expensive than elsewhere in the country, and it's becoming harder and harder to find a doctor to see even if you are covered," Perry wrote in an Austin-American Statesman op-ed shortly after President Obama signed the Affordable Care Act.
While Perry's claims may be slightly exaggerated, Massachusetts' insurance premiums have become more expensive since Romney signed his health care law.
Premium cost increases outpaced the national average in 2009, increasing by 10 percent for private insurance compared to a 4.6 percent increase nationally, according to the Massachusetts Division of Health Care Finance Policy. Health care changes in Texas have been primarily related to family planning funding and women's health. In the past legislative session, Perry fast-tracked a sonogram bill that requires women seeking an abortion to have a sonogram at least 24 hours before the procedure.
The sonogram bill also requires doctors to describe the size of the fetus' limbs and organs, even if the woman does not want to hear it and make the sonogram image of the fetus and its beating heart available to the woman.
"We are facing a $27 billion budget deficit, and this was an emergency item," said Yvonne Gutierrez, a spokeswoman for Planned Parenthood Trust of South Texas. "This was one of those incidents where you knew this was wrong. This has nothing to do with the health of our state or with anyone being informed or any effort to make better the situation in Texas surrounding our budget."
The Texas Legislature also passed a bill this session that cuts about $64 million from family planning centers and redirects that money to faith-based pregnancy centers, which do not provide abortions, and to other services such as at-risk youth programs.
In 2005 Perry signed a bill requiring women younger than 17 to get parental consent for an abortion, strengthening a 1999 law that he helped get through the legislature as lieutenant governor that required parents to be notified but not necessarily give consent.
Perry's signing of the parental consent law caught national media attention because he held the signing ceremony in a Christian school.
"Gov. Perry has been very helpful in passing measures that help steer women to alternatives to abortion. He has been an ardent defender of the sanctity of human life," said Elizabeth Graham, the director of Texas Right to Life.
Romney's abortion stance, on the other hand, was less defined during his term as governor. While running for office in 2002 Romney said in a debate against his Democratic opponent Shannon O'Brien that he supported abortion righrs.
"I will preserve and protect a woman's right to choose," Romney said. "I am not going to change our pro-choice laws in Massachusetts in any way. I am not going to make any changes which would make it more difficult for a woman to make that choice herself."
But as governor, Romney vetoed a bill that would expand access to emergency contraception, writing in an op-ed explaining his veto that he was "pro-life."
"While I do not favor abortion, I will not change the state's abortion laws," Romney wrote in 2005.
Most recently, Romney defined his position in a National Review op-ed in June in which he wrote that he supported defunding Planned Parenthood and overturning Roe v. Wade, a very different position than the one he took when running for governor. His change of heart has spurred attacks from both both Republicans and Democrats.
"No matter which side you're on, I think that Mitt Romney doesn't have any credibility on reproductive rights," said Tricia Wajda, director of public affairs for Planned Parenthood League of Massachusetts. "The only rights he's interested in protecting is his own right to waffle on his own positions."
Fellow presidential contender Michele Bachmann took a stab at Romney's record in June at a National Right to Life convention.
"This is not the time for the Republican Party to put up a candidate who is weak on the pro-life issue or has a history of flip-flopping over it," Bachmann said.
While social issues are being eclipsed by economic woes at the national level, they are important as ever in early primary states like Iowa and South Carolina, which was born out by the prevalence of anti-abortion and defense-of-marriage applause lines at the Ames Straw Poll last weekend.
None of the previous or current governors in the presidential race competed in the straw poll, but Perry still captured 150 more write-in votes than front-runner Romney, a surprisingly good finish considering the Texas governor did not announce his candidacy until the day of the poll.