10/11/2012 05:41 pm ET Updated Dec 11, 2012

What We Talk About When We Talk About Emergency Rooms


The one presidential debate on domestic issues has come and gone, and like everyone else, I am disappointed -- not because of what was said about Big Bird or taxes or even small business, but because of what was not said about health care options for those struggling in our country.

For me, Romney's most telling statement on the issue did not come in the debate but during his 60 Minutes interview a week or so earlier. It said a lot about how not just the candidate, but also the American public, has been coached to think about the social safety net.

To refresh your memory, his statement -- "Well, we do provide care for people who don't have insurance. If someone has a heart attack, they don't sit in their apartment and die. 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." -- has been widely criticized by anyone who knows anything about health care delivery in the U.S., starting with Romney's own 60 Minutes interviewer Scott Pelley.

"That's the most expensive way to do it," he told Romney.

As many have noted, back in his health care reforming days the former Massachusetts governor did acknowledge that emergency room care is the most costly, least effective way of delivering health care. No surprise there. After all, uncompensated emergency room bills total tens of billions of dollars each year, a tab that is essentially covered by the paying public.

So why did Romney open his mouth and spout rhetoric that he is firmly on record as rejecting?

There are two ways to understand the candidate's remarks on emergency rooms. While neither interpretation is particularly flattering, each tells us something about the way he understands large social problems.

The first is that Romney honestly disagreed with the premise of the question ("Does the government have a responsibility to provide health care to the 50 million Americans who don't have it today?"), and believes that all Americans do, in fact, have health care thanks to the protections of the Emergency Medical Treatment and Active Labor Act (EMTALA).

Assuming that you are in fact experiencing an emergency as defined by EMTALA, and that you can get yourself to a hospital emergency room while experiencing said emergency, and that you are not at the mercy of an ambulance or hospital that is unconcerned with the niceties of the law and refuses to treat you notwithstanding your emergency, and that you don't require any continuing care once stabilized (or, heaven forbid, hospital admittance), then sure, all Americans have care.

Under this reasoning, there are no homeless Americans because any American can find a bed at a homeless shelter. There are no hungry Americans because anyone who wants to line up outside a food kitchen is welcome to do so.

This rational offers viewers (and voters) just enough to assuage their consciences about heartstring-tugging personal stories while still rejecting the need for a systemic response to what is in fact a systemic problem. ("Don't worry about poor Oliver Twist -- in this country our orphans all get a roof over their heads and on-the-job training!")

The second way to interpret Romney's remarks is not as a rejection of the question's premise, but a refusal to recognize consequences. If you're having a heart attack you can always go to the emergency room? He may have well as said, "Hey, no one is going to die if we don't do anything."

This framing is emblematic of how many people seem to understand government programs that are so improbably at the center of debates this presidential season: by focusing on the individual rather than societal impact. Mr. Heart Attack won't die today, perhaps, but how does a do-nothing solution help our larger community in the long run?

Don't get me wrong; individual stories are compelling, and they certainly make the nightly news interesting. But that does not mean that bureaucracies do not have an important role to play in creating solutions to individual problems. Programs like Medicaid do not help "them"; they help us. All of us.

Emergency stop-gap measures to help individuals in crisis are well and good in a crisis situation. But we have systemic issues in our delivery of health care in this country that call for systemic solutions. Mitt Romney once knew that. I hope he finds occasion to remember it again.