Mitt Romney's Health Care Advantage?

Conservative pundits are in high dudgeon over Mitt Romney's May 12th health care address. Their explosions of indignation, sadly, have shown contextual ignorance and ideological incoherence. Romney has grappled with health care in greater depth than any other Republican contender and has unique and powerful insights into ObamaCare's procedural and substantive flaws. As a long-time supporter of Romney, I predict that he will not only survive this round of demagoguery, but he will prevail in the primaries and his health care experience will be a tremendous advantage in the general election.

But let's back up. In order to understand RomneyCare, ObamaCare, and the health care debate in general, one must first understand basic principles and fundamental political realities. We do not currently have a free market medical system. We already have a form of federally mandated universal health care. The 1986 Emergency Medical Treatment and Active Labor Act requires all hospitals receiving Medicare and certain other government funds (which is to say, almost every hospital in the nation) to provide ambulance and emergency medical care to all patients regardless of their ability to pay.

Such a mandate (signed into law by Ronald Reagan) destroys any semblance of a truly free market. Imagine how radically it would distort the automobile market if you could enter a dealership and demand a car regardless of your ability to pay. Yet despite its profound market-altering effects, the universal care mandate is relatively uncontroversial. Why? Because it taps into a common moral sensibility. It is deeply offensive to a culture that preserves and protects human life to deny medical care to the sick or injured. But as you might imagine, the cost effects of this law have been significant.

Let's make this concrete. Imagine a Cambridge hipster named Brian. Brian is 27 years old, has never had a serious illness or injury, runs four miles a day, plays ultimate Frisbee on the weekends, and doesn't have health insurance. One day, as Brian rides his bike to Whole Foods, a Chevy Volt broadsides him. The electric engine was just too darn quiet. He never heard it coming.

Three days later, Brian wakes up in a hospital room and realizes that the entire apparatus of modern medicine was mobilized to save his life, from EMTs to ER physicians, to neurosurgeons, to hospitalists, to nurses who watch him night and day. He's had MRIs, CAT scans, X-rays, and three rounds of extensive surgery.

What should happen to Brian? The hospital has spent $100,000 saving his life, but he has no insurance. Should it yank out the IVs, put him out on the street, slap a lien on his assets, and commence collection proceedings? Federal law says no. Brian stays and Brian gets care—and I'm glad he does. No one wants poor Brian to die.

However, while we are morally, culturally, and legally obligated to provide a certain level of health care to our citizens, health care is extraordinarily expensive, and our country is poised on the edge of fiscal ruin. The delicate dance between these truths defines any serious health care debate, the kind of debate we should be having—and reconciling these truths within our constitutional framework is one of the central policy challenges of our time.

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.