Mitt Romney's Mindbending Flip-Flop on Emergency Rooms and Health Care

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The Republican waves off the free-rider problem -- and shows how hard it is to be for small government and fiscally conservative at the same time.

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Pop quiz: The following two statements both argue that mandatory health insurance is important to avoid "free riders" getting care on the public dime at the emergency room. Match the statement with the 2012 presidential candidate who delivered it.

  1. "When uninsured people who can afford coverage get sick, and show up at the emergency room for care, the rest of us end up paying for their care in the form of higher premiums."
  2. "If somebody could afford insurance they should either buy the insurance or pay their own way. They shouldn't be allowed to just show up at the hospital and say, somebody else should pay for me."

Stumped? Don't feel bad: They're basically indistinguishable. (Though if you must know, the first is Barack Obama and the second is Mitt Romney.)

The free-rider problem is pretty straightforward. Because we as a society have decided that it's inhumane to let sick people die on the steps of our hospitals, we require those hospitals to care for those who show up, whether they can pay or not. But someone has to pay for their care, and when hospitals don't get government reimbursement for indigent patients they have to absorb the costs themselves, which they manage by raising prices for everyone else. The solution devised by Romney, as Massachusetts governor, and the U.S. Congress, in "Obamacare," was to require anyone who could pay for insurance to buy it up front or pay a fine, and to provide a government subsidy for insurance to those who can't afford it. Even when the public pays for the subsidy, it turns out to cost less than having people to use emergency rooms as their primary care facilities. Romney made the same point in his book No Apology and a half dozen other venues.

Now, here's Romney on 60 Minutes Sunday night:

PELLEY: Does the government have a responsibility to provide health care to the 50 million Americans who don't have it today?
ROMNEY: Well, we do provide care for people who don't have insurance, people -- we -- if someone has a heart attack, they don't sit in their apartment and -- and die. We -- we pick them up in an ambulance, and take them to the hospital, and give them care. And different states have different ways of providing for that care.
PELLEY: That's the most expensive way to do it.
ROMNEY: Well the...
PELLEY: In the emergency room.
ROMNEY: Diff -- different, again, different states have different ways of doing that. Some -- some provide that care through clinics. Some provide the care through emergency rooms. In my state, we found a solution that worked for my state. But I wouldn't take what we did in Massachusetts and say to Texas, "You've got to take the Massachusetts model."

Wrenchingly, this stance is turned 180 degrees from his earlier position. In order to please conservatives wary of his record, Romney has said for some time that other states need not imitate Massachusetts' system -- though that was also a reversal from 2009, when he wrote in USA Today that the Bay State should be a model for reforming the national system. That may have been a flip-flop, but it was in response to actual concerns about the authority of the federal government.

In two cases, Romney has effectively taken a position that leads to the government spending more money.

His more recent comments appear to be something different: Romney is basically saying that the cost savings don't matter. And that's a strange perspective, as both the pragmatic technocrat and the disciplined fiscal conservative he insists he is. Candidate Romney doesn't provide an alternative explanation for how he'd keep the public from paying for free riders (you can read a brief summary of his plan here), and that's a huge chunk of taxpayer dollars: a 2004 Kaiser Family Foundation survey calculated that free riders cost the federal and state governments almost $35 billion per year.

This reversal is awfully reminiscent of the fabled $716 billion Medicare cuts that came as part of Obamacare. Those aren't cuts to service, but rather reductions in the growth of the payments the government gives to providers. In his own budget, Paul Ryan assumed those reductions would stay in place. But Romney quickly disavowed that (and Ryan got in line), saying that he didn't want the federal government instituting the cuts. That means that President Romney would have to reach the same spending levels he pledged before, but do so while cutting nearly a trillion bucks more. As Derek Thompson pointed out, that's simply not going to happen.

On both the free-rider question and the Medicare question, Romney has effectively taken a position that leads to the government spending more money. In the first case, he was unwilling to challenge the notion that Americans shouldn't be allowed to die in the streets. In the second, he was unwilling to challenge the notion that senior citizens ought to receive government care. Both those stances are rational, but they point to a central irony of the Tea Party era: You can either be for smaller government, or you can be fiscally conservative -- but it's nearly impossible to do both.

Updated, September 25: My National Journal colleague Meghan McCarthy points out that the theory behind the free-rider fix hasn't yet been totally proven in Massachusetts. Because of rising health-care costs overall, the state government isn't spending less money yet. In short, the jury's still out on whether the savings from making sure the ER isn't the provider of last resort are worth it. But of course, that's not the argument Romney made on 60 Minutes.

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David A. Graham

David Graham is a senior associate editor at The Atlantic, where he oversees the Politics Channel. He previously reported for Newsweek, The Wall Street Journal, and The National.

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