How did Mitt Romney handle this challenge in Massachusetts?

First, he recognized his state's unique assets and nature. Massachusetts has an extraordinary concentration of health care assets, with some of the finest hospitals and doctors in the world. But "the best" typically means "the most expensive," and for a very long time health care has cost more in Massachusetts than anywhere else.

Fortunately, Massachusetts is also a wealthy state. One of the wealthiest. It also has among the highest percentage of residents with health insurance in the country.

The (very) liberal Massachusetts legislature looked at these realities and tried to further expand coverage through a substantial, direct tax on businesses that did not already offer health care. In other words, the legislature was prepared to directly and punitively burden small business to expand health care coverage. Mitt Romney offered an alternative—the individual mandate—that would narrow the coverage gap while providing much less direct burden on the small businesses that often fuel the engine of economic growth.

The hope (the never-before-tried idea) was that the newly-insured Bay Staters would start making health care decisions more like their previously-insured neighbors. Once covered, it was thought, people like Brian would make better use of primary care physicians and place a lesser burden on costly emergency rooms.

Has it worked? Yes and no. The plan has absolutely worked to increase health insurance coverage. Massachusetts has by far the lowest rate of uninsured citizens in the country. At the same time, however, patients still go to the emergency room too often, and Massachusetts still struggles with health care costs. Yet those costs have hardly spiraled out of control. The idea (spread in some circles) that the individual mandate has bankrupted the state or led to uncontrolled cost growth is simply a "myth." The Massachusetts Taxpayer Foundation has calculated the additional financial impact as roughly 1.2 percent of the state budget. The increased cost is not good, but it's hardly backbreaking.

Now, let's contrast Mitt Romney's approach with President Obama's.

First, the President took an approach (the individual mandate) that had previously been tried only in one of America's wealthiest states with a relatively low percentage of uninsured and imposed it on the entire country.

Compare this chart, showing relative state median income, with this chart, showing percentages of uninsured by state. See any differences? Arkansas is relatively poor ($37,823 median income, 48th in the country), with a high percentage of uninsured (19.2 percent in 2009). California has high income ($58,931) and a high percentage of uninsured (20 percent). Then there's Massachusetts, with high income ($64,081) and a low number of uninsured (4.4 percent). With higher percentages of uninsured come much, much higher costs in an individual mandate.