RomneyCare: Health Security Theater?


Former Massachusetts Governor and current GOP presidential wannabe Mitt Romney is set to give a big speech on health care this afternoon: Judging by the op-ed he published in yesterday's USA Today, he won't spend much time talking about his role in passing RomneyCare, the state-based health program that served as the model for ObamaCare. I'd like to see him disown the program entirely, but if he'd rather defend it, he might look to The New Republic's Jonathan Cohn, who consistently does a better job of defending RomneyCare than Mitt Romney does. 

Today, Cohn responds to what is perhaps The Wall Street Journal editorial board's most brutal attack yet on the state-based system that paved the way for ObamaCare. You should read the Journal's takedown of the plan Romney signed into law, and you should read Cohn's defense: Side by side, they provide a handy way to compare the cases for and against the law. 

The Journal makes the case that it's a broken, unaffordable system that, rather than encouraging "personal responsibility" (as Romney argued), has put most of its beneficiaries on the public dole without getting rid of the burden on emergency rooms or solving the problem of uncompensated care: Emergency room usage went up by 9 percent between 2004 and 2008, and state spending on uncompensated hospital care rose between 2008 and 2010. 

In a previous defense of the system, Cohn admitted that the "big flaw" in the system is that "it hasn't controlled the rising cost of medical care," though he says the authors of the plan weren't really trying, and that they're now working on getting its finances in order. This time, he zeroes in on the Journal's argument—similar to the one I made earlier this week—that the only thing that's worked about RomneyCare is that it has increased the percentage of the state's population with health insurance coverage. Here's Cohn:

But the most revealing sentence in the Journal editorial is this one:

"The only good news we can find is that the uninsured rate has dropped to 2% today from 6% in 2006." Yes, and the only good news in foreign policy lately is that American forces finally killed Osama Bin Laden.

In turn, I would say that the last line quoted above is the most revealing sentence in Cohn's post: As far as I can tell, he's suggesting that expanding the Bay State's insurance coverage, like taking out bin Laden, was a considerable victory that should not be dismissed or underweighted in any overall assessment; in particular, expanding coverage during a recession should be seen as a major achievement.

I think the comparison works, but not in Cohn's favor: Taking out Bin Laden was a success. But it took far too long, cost far too much, and involved a massive, needless sacrifice of Americans' civil liberties. America created an expensive new security agency, nationalized airport security, and spent almost $1.3 trillion (and counting) and countless lives on two ill-advised wars. As Cato's Christopher Preble told me last week, much of what we've done, and much of the cost we incurred, in our post-9/11 war on terror has been not merely wasteful but actively counterproductive. Taking out Bin Laden was a real, and necessary, victory. But it's exceedingly difficult to defend the expensive, poorly thought out, roundabout methods that eventually led us to him. 

The push to expand health insurance via mandates and public subsidies isn't perfectly analogous, but there are more than a few similarities. Analyst Bruce Schneier likes to talk about "security theater," his term for when governments spend a lot of money on showy countermeasures that primarily increase the feeling of security without actually enhancing it. Government-implemented expansions of health insurance, which is not the same as access to health care, work much the same way: Health insurance certainly makes people feel secure in their health. But when it takes longer and longer to see a doctor, and fewer practices are taking new patients, how real is that security?

As we've seen with the introduction of Medicare, which didn't cause any significant drop in seniors' mortality during its first decade, and with Medicaid, whose beneficiaries frequently do worse on many health measures and whose administrators admit to having no evidence that it works, the health benefits of carrying insurance are not as strong as one might think. Nor, as we've seen with emergency room crowding—which, as the Journal notes, has recent in recent years in Massachusetts despite Romney's claim that RomneyCare would address the problem—does expanding insurance coverage solve the public policy problems it's supposedly intended to fix. Government-driven expansions of health insurance are arguably a form of security theater for health safety: Call it Health Security Theater. 

Meanwhile, focusing on expanding health insurance coverage continues our national emphasis on trying to help people's lives by giving them greater and greater amounts of medical treatment. But as economist Robin Hanson has noted over and over again, the relationship between health and medicine is surprisingly weak. A large amount of medical care is probably what Hanson calls "heroic medicine": doing more primarily to be seen to do more

When politicians push to expand health insurance on the public dime, they're engaged in a sort of political version of Hanson's heroic medicine: doing something to be seen to do something in hopes that it will look like they care. But much of it ends up looking a lot like Health Security Theater, primarily increasing the "sense" of health security through expensive and highly visible acts. America's decade-long experiment with security theater hasn't solved many of the problems it was supposed to solve, but it has cost us a lot of time, personal liberty, and money. The early evidence from RomneyCare suggests that our experiment with Health Security Theater may well turn out the same. 

Here's my response to Cohn's 2009 defense of RomneyCare.