Befitting his status as the GOP's presidential front-runner, Rudy Giuliani has avoided all direct attacks on Republican rival Mitt Romney.
It was a strategy that continued when Giuliani unveiled his health care plan earlier this week, aiming his criticism at the top three Democrats running for president.
But in assembling his team of health care advisers, the former New York mayor tapped Sally Pipes, a sharp critic of the state-level mandates and regulations backed by Romney, who leads in the crucial states of Iowa and New Hampshire.
Pipes, a health policy expert now advising the Giuliani camp, has been vocal in her criticism of the former Massachusetts governor.
"Massachusetts Will Fail," blared the headline of her April 10, 2006, USA Today op-ed. In The Wall Street Journal, Pipes accused Romney of being "in cahoots" with liberal Sen. Ted Kennedy, D-Mass., in a June 28, 2007, op-ed. She warned in a May 15, 2007, op-ed for the Boston Globe that the structure of the Massachusetts health care plan is a "gourmet recipe for runaway spending."
The battle lines emerging between Giuliani and Romney on health care reverse the established pattern on social issues. Where Romney falls to Giuliani's right on abortion rights and a federal amendment banning same-sex marriage, on health care it is Giuliani who has positioned himself as the more strident conservative.
Giuliani and Romney both oppose a federal requirement that individuals purchase health insurance.
The two Republicans differ, however, on whether it is wise for an individual state to mandate that its residents purchase health insurance as Massachusetts did under Romney.
Addressing Giuliani's take on mandates from San Francisco, where she heads the Pacific Research Institute, a free-market think tank, Pipes said, "I would say in principle he doesn't support individual mandates. Because he supports a consumer-driven, ownership society, that would preclude the individual and employer mandate at the state level."
Massachusetts adopted an individual mandate in order to address the free-rider problem that occurs when emergency rooms, required under federal law to provide a certain level of treatment to everyone, are forced to treat a patient who is unable to pay. Those costs end up shifting to taxpayers as well as to those in the state who have insurance. Romney wanted to cover the uninsured so they could be treated in less expensive ways.
"One of the data discoveries that emerged from the process of crafting the Massachusetts plan was that many of those that didn't have coverage were younger, healthy citizens who could afford insurance, but didn't purchase it because they figured they were healthy and if anything went wrong they could go to an emergency room and the taxpayers picked up the bill," Romney spokesman Kevin Madden told ABC News.
On the philosophical level Giuliani's adviser objects to a system that indirectly taxes "the young and healthy -- who typically have both less income and less wealth -- to subsidize those who are older and less healthy" by requiring them to purchase insurance.
Pipes also takes issue with Massachusetts imposing a fee on employers who do not make any provision for insurance.