Wolf Blitzer put a terrific question to Rep. Ron Paul at last night's CNN/Tea Party Express Republican debate in Tampa, Fla. What should happen, the moderator asked hypothetically, if a healthy 30-year-old man who can afford insurance chooses not to buy it—and then becomes catastrophically ill and needs intensive care for six months? When Dr. Paul ducked, fondly recalling the good old days before Medicare and saying that we should all take responsibility for ourselves, Blitzer pressed the point. "But, Congressman, are you saying the society should just let him die?" At that point, the rabble erupted in cheers and whoops of "Yeah!"
This was indeed an appalling, mob-mentality moment—more medieval, even, than the crowd applauding Gov. Rick Perry for winning the death-penalty derby at the previous debate. What it clarified, however, was less the cruelty of the Tea Party crowd than the absurdity of the health-care positions of all of the Republican candidates. The GOP contenders relentlessly attack "Obamacare" as "socialized medicine." But they won't speak up for either of the other two choices available to them: the arguably more socialized system we have hitherto lived with or the Blitzer option of letting the uninsured die in the streets.
Let's walk through our options.
The first is a system with an individual mandate of the kind included in the Obama bill, or what Romney enacted in Massachusetts in 2006. Under this kind of system, individuals are not given a choice about whether to insure themselves. If they fail to meet the insurance requirement, they pay money, which you can call a fine or a tax, as you prefer. Under this alternative, the costs incurred by Blitzer's young man are not broadly socialized because they are covered by the fine on those who avoid signing up for insurance.
The second option is our current system, or other systems without mandates. In this universe, our hypothetical young man receives at least emergency care because hospitals are required to treat the urgently ill without regard for their ability to pay, thanks to a bill signed by Ronald Reagan in 1986. But the costs of his treatment are not absorbed by the hospitals. They are passed on to consumers, employers, and the government in the form of higher insurance premiums. One 2009 study estimated the cost absorbed by those who are insured for those who aren't at $1,100 per family. This is one of the ways in which the pre-Obama health care system is socialized—indirectly, inefficiently, and unfairly.
The third option is that of the Tampa Tea Party mob: Let the young man go to the devil. You can sugar-coat this, as Ron Paul tried to, by suggesting that private charity will step in to help. But we no longer have an extensive system of charity hospitals. If emergency rooms treat the uninsured, whether because of a legal requirement or because they are good Samaritans, they will be passing the bulk of the cost along to the rest of us—and we're back to our current system of socializing the costs of treatments for the uninsured.
Of the Republican candidates, only Romney clearly supports a version of the first choice: the mandate. To his credit, the bill Romney signed in Massachusetts has led to his state having the lowest percentage of uninsured people in the country. Where his current position falls into absurdity is in its race for a federalist life-raft. Romney now says that states should come up with their own systems, the way his did. But each state having its own health care system would be the bureaucratic nightmare to end all nightmares. And unless you believe all 50 states will embrace individual mandates (and many clearly will not), the costs produced by Blitzer's hypothetical young man will continue to be socialized in ways not strictly circumscribed by state borders.
Jon Huntsman has moved from the first to the second category. In Utah, Huntsman preferred a plan with an individual mandate. But he lost that fight with his legislature. Without a mandate, his bill has been far less effective at covering the uninsured than the one in Massachusetts. Fourteen percent of Utah's population remains uninsured, compared with only 5 percent in Massachusetts. Huntsman touts his system as superior to Romney's because it has no mandate. But the real distinction is that in addition to not doing much for the uninsured, it continues to pass along their expenses to the rest of society.
Newt Gingrich's position is muddle and gibberish, if anyone even cares. Historically, Gingrich has supported an individual mandate. In May, he went on Meet the Press and told David Gregory that health insurance should be required, like automobile insurance. People should either buy it or "post a bond" (a version of a mandate). But then the right wing went nuts, and Gingrich posted a video saying, "I am against any effort to impose a federal mandate on anyone, because it is fundamentally wrong and, I believe, unconstitutional."
Rick Perry and Michele Bachmann seem to share some version of Ron Paul's libertarian position that death is a great instructor of personal responsibility. Details remain to be worked out around the disposal of corpses and the distribution of orphans. But, say what you will, theirs is not a socialist approach.