Article VI Blog

No doubt, most view Romney's greatest accomplishment as governor is the health care plan he made happen. (Although, his actions in the Big Dig mess and most recently in response to the foiled terror plot may be changing that.) It is being broadly discussed as the wave of the future. There is a good analysis here.

The plan is an excellent, provided that one accepts that health care is an entitlement. I realize that such acceptance is a public reality and a political necessity, and yet I am unwilling to make it personally. While not a libertarian on most things, I find myself passionately libertarian when it comes to matters of health and health care.

Before I launch into this completely, I want to state that I do not think the nightmarish problems that I am concerned with are the intention of Romney or anyone else that brought the new system to pass. But there is such a thing as the Law of Unintended Consequences. Who knew that the welfare system of the early 60's would result in the virtual destruction of traditional family structure in the poor of America and particularly in the Afro-American community?

One's health is, save perhaps for one's spiritual state, the most personal aspect of one's life. What we eat, how we spend our free time, who we have in our bedrooms, all are issues related to health and health care. As health care becomes an entitlement, the providers of that entitlement will be obligated to control the costs and one way they will do so is by trying to control these very private choices of an individual.

For example, because HIV is primarily transmitted via homosexual activity, would not health care providers seek to limit such activity? Conservatives might not mind that too much, so let's look at some other examples. The Hindu religion mandates vegetarianism, at least some forms of it. Suppose this diet was shown to have health ramifications - now what? Can we force Hindus to eat meat, or can we force everyone to become Hindu? What about the use of psychotropic drugs by some religions? And those are just the obvious examples. What about family size limitations? Do we really want to end up like China?

Some recent studies attribute long life to religious faith - shall faith now be a government mandate? If so what religion? These kinds of things are being discussed today. We've seen it with smoking and now we are seeing it with weight. When health care is an entitlement, you are required to have policies about things that the government just should not be having policies about - personal, private matters. Thus, while I think Romney's plan is excellent if we accept healthcare as an entitlement, I think it is a mistake to do so.

Lowell: I've spent the last 20+ years in the heath care industry, so this is an issue near and dear to my heart. John has identified the most common "hot button" objection to Romney's plan: The "individual mandate," which requires everyone to have health insurance of some kind, much like many states require everyone to have auto insurance. The new Massachusetts law is described in (somewhat wonkish) detail here. (Full disclosure: The last link is to a newsletter published by my law firm, and in which I had a hand.)

The Romney plan does get a mixed reaction in the conservative community. The individual mandate is anathema to libertarians; but the plan was crafted in close cooperation with the Heritage Foundation, an organization with impecable conservative credentials. My response to John is long, but I'll summarize here:

First, I feel your pain. I am not in love with the idea of the government requiring citizens to spend money on an item as personal as health insurance. I also am worreid about the unintended consequences.

Second, however, I think the pain is necessary. The auto insurance analogy is useful in this regard: As a society in which the automobile is a ubiquitous and indispensible element of our lives and our economy, we have come to accept the fact that the costs to all of us from a libertarian approach to auto insurance would be catastrophic. (A libertarian purist would disagree with that statement, but I think I'm right.)

Similarly, the health care industry now represents about 16% of our gross domestic product. It is simply a huge part of our lives. Also, and just as important, I believe we have made a decision as a society that everyone is entitled to a minimum level of health care. One can disagree with that decision, but I believe it has been made; it might well be described as part of the American social compact by now.

Given that, I do not see the U.S. returning to Charles Dickens' England, where people had to depend on the mercy of others to get good care. (I know John is not even close to arguing for that; it's simply a point of contrast.) In other words, we are simply not going to tolerate a system in which people will be forced to do without health care. There is a religious component to this view (witness the many Catholic and Adventist hospitals in existence), as well as a social democratic "nanny state" element, but it is undeniably woven into the fabric of our society.

My opinion: Given the immutable nature of that societal compact, the Romney plan is an ingenious form of social policy jiu-jitsu that turns us away from creeping socialist approach and actually incorporates free market principles of individual autonomy, even as it encroaches on citizens' freedom not to have health insurance. The Heritage Foundation notes the Romney plan's achievements:

1. Creation of a new market for health insurance in which individuals and families can buy private coverage of their choice, own it, and take it from job to job without losing the existing favorable tax treatment for employer-sponsored health insurance, and

2. Creation of a new system of premium assistance for lower-income individuals to purchase private coverage based on leveraging existing uncompensated care funds used to cover the cost of care for the uninsured.

"These two components," say the Heritage authors,

could revolutionize the traditional health care system by empowering individuals, including low-income persons, to buy and own their health care coverage, and they can be adapted to the unique conditions of other states.

So the Romney healthcare plane is a mixed bag. There's that non-libertarian individual mandate, but there's so much more that empowers individuals, which at the same time just might solve the problem of the uninsured in this country. If the plan works, 95% of Massachusetts citizens will have insurance within three years, and they'll have it in a free market, not in a single payer health system like Britain's disastrous National Health Service or the quickly deteriorating Canadian system.

As for the religion angle, as long as we have a plan that incorporates individual autonomy with market principles, the chance that unintended consequences, of which Jon rightly warns, will encroach on our personal beliefs seems pretty small. But it's an experiment. Let's see how it unfolds. If the Massachusetts system fails in the short term, Romney's fortunes will take a huge, probably unsurvivable hit. If it succeeds or is perceived as succeeding, he'll be sitting pretty.

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